Methods for improving the clinical outcome of patient care and for reducing overall health care costs

ABSTRACT

System and method for reducing healthcare costs by improving care and encouraging healthy behaviors. A web-based or telephonic program using health plan sponsor funded financial incentives, offered to patients and providers for declaring or demonstrating adherence or providing a reason for non-adherence to performance standards. Financial incentives are contingent upon patient&#39;s and provider&#39;s agreement to allow the other to confirm or acknowledge the other&#39;s declaration or demonstration of adherence or non-adherence reason. Combining financial incentives with a set of checks and balances motivates participation in the program and adherence to the performance standards. Performance standards include evidence-based treatment guidelines, information therapy, wellness and prevention solutions, care management, and other methods proven to control costs by improving behaviors and healthcare. The system and method achieves improved health and more affordable healthcare by aligning the interests of providers, patients/consumers, and health plan sponsors in a win-win-win arrangement.

CROSS REFERENCE TO RELATED APPLICATION

This application is a continuation of U.S. patent application Ser. No.13/492,441, filed Jun. 8, 2012, now U.S. Pat. No. 9,171,285, which is acontinuation-in-part of U.S. patent application Ser. No. 13/166,467,filed Jun. 22, 2011, which is a continuation of U.S. patent applicationSer. No. 11/596,305, filed Dec. 13, 2007, which is a 371 ofPCT/US2005/015791 filed May 6, 2005, which is a continuation-in-part ofU.S. patent application Ser. No. 10/841,240, filed May 6, 2004, thecontents of which are incorporated herein by reference.

BACKGROUND OF THE INVENTION

A challenge confronting modern civilization is how to provide healthcareto all the members of a society. When stated in this way, the challengetranscends the issue of whether healthcare is a right or a privilege. Iteven exceeds the questions about how much healthcare and what quality ofhealthcare is a society to receive. Moreover, the challenge is a matterof economic reality—how can society afford universal healthcarecoverage. When all is said and done, and there has been lots said anddone with regard to this challenge, there are only a handful ofconsistencies that define the challenge and it is these consistenciesthat lead us to the solution,

The following are the consistencies that frame the challenge:

-   -   Health Status of the Citizens Obviously, a society with a        population of healthy versus unhealthy people is better able to        provide universal healthcare coverage.    -   Efficiency and Effectiveness of the Healthcare Delivery System A        society with a healthcare system that delivers high quality        clinical outcomes for the least amount of resources is better        able to provide universal healthcare coverage than a society        with a healthcare system that is dysfunctional and delivers low        quality clinical outcomes,    -   Affluence of the Society Rich countries are better able to        provide universal coverage to its citizens than poor countries.        In fact, a country's affluence depends in large part on the        health status of its citizens.

Simply stated, a rich country with healthy people and an efficienthealthcare delivery system is in a much better position to provideuniversal healthcare coverage than a poor country with unhealthy peopleand a dysfunctional healthcare system. It follows that a societyincreases its ability to provide universal coverage by improving itseconomy, its citizen's health status and its healthcare delivery system.So, the challenge can be distilled further to the objective of improvinga society's economy, public health status and healthcare deliverysystem, and then maintaining these factors at levels that allow thesociety to afford universal healthcare coverage.

The United States presents an interesting combination of factors thatcomplicate the challenge. The U.S. is an affluent country with decliningpublic health, a largely dysfunctional healthcare delivery system, andsince 2008, a struggling economy. Americans spend considerably more onhealthcare per capita than citizens of any other developed country, andyet Americans' life expectancy and infant mortality rates rank towardthe bottom of the list of these countries. For decades, the growth rateof healthcare expenditures in the U.S. has grown two to five times therate the economy at large, consuming an ever increasing segment of thecountry's gross domestic production (GDP). Unlike other developedcountries that provide government-sponsored universal healthcarecoverage, the U.S. is the only country in which a majority of citizensreceive healthcare coverage through their employers or by purchasinghealth insurance from a commercial insurer. Beginning in the 1990s andcontinuing to the present, the number of Americans without healthinsurance coverage or are under-insured has grown because it is becomingincreasingly unaffordable. Current estimates place the number ofuninsured at 45,000,000 to 47,000,000, which represents an all-time highof 17.1% of the U.S. population as of 2011. At the same time, the annualcost of healthcare coverage for a family of four exceeded. $20,000 forthe first time as of 2012.

Fueling this growth in healthcare costs and the uninsured is thedeclining healthcare status of Americans. The U.S. is far and away themost obese country on earth. According to the Center of Disease Controland Prevention (CDC) latest survey for 2010, 35.7% of American adultsare obese. This compares with less than 15% in 1980, 24.2% for the nextmost obese country (Mexico), and 14.1% for all developed countries.Obesity is a well-known cause of all sorts of serious maladies that areexpensive to treat such as diabetes, heart disease, hypertension, andmetabolic disease. It is also a well-known fact that obesity can beprevented with better diet and exercise. Studies clearly show thatpreventing and reversing obesity along with other preventable healthissues such as smoking, poor medication adherence and health illiteracyat a moderate level could save enough overall to provide finds to coverall the uninsured and then some.

Complicating matters is the fact that the supply of U.S. physicians totreat these diseases is also becoming an increasingly critical problem.The number of people tilling medical school slots has not kept pace withthe demand, especially for primary care physicians. Currently, theUnited States ranks 43^(rd) in the world in the number of physicians percapita and this shortage of physicians is occurring just as the“baby-boomer” generation begins to reach retirement age. The simpleeconomic law of supply and demand will only add inflationary pressure onan already hyper-inflating situation.

Since the mid-1980s, several attempts have been made to controlhealthcare costs. The attempted reforms only temporarily slowed theescalation of healthcare costs during the mid to late 1990s, when healthmaintenance organizations (HMOs) incented medical service providers tocontrol healthcare utilization. Successful lawsuits by patients thatfound HMOs rationed care and the threat of federal legislation(Patients' Bill of Rights) caused a dramatic decline in HMOs. Otherapproaches in which health plan sponsors (health insurance companies,self-insured employers or government programs) compensate medicalservice providers (principally physicians) to improve the quality andefficiency of healthcare quality in an attempt to bend the so-calledcost curve include:

-   -   the pay-for-performance movement—a concept that assumed improved        care quality would lead to cost containment;    -   accountable care organizations (ACOs)—a concept that essentially        mirrors HMOs with a focus on improved quality to prevent the        suggestion of rationed care;    -   patient-centered medical homes (PCHMs)—a concept that uses        primary care providers and health information technology to        coordinate better care;    -   the adoption of interconnected electronic health record (EHR)        systems to help make healthcare more effective and efficient.

Again, the reoccurring theme with each of these approaches involves thehealth plan sponsor compensating medical service providers to changetheir practice patterns in an attempt to bend the cost curve. The othercharacteristic common to these approaches is that patients (planmembers) are not held accountable for their health behaviors, andtherefore, are left out of the equation.

Another movement attempting to resolve the issue of healthcare coverageaffordability involves approaches in which the plan sponsor financiallyrewards the patient to improve his/her health behaviors. Examples ofthis approach include: wellness, prevention and care management programsthe patient (plan member) earns financial rewards for participating inthese programs and/or for achieving specific health objectives;

-   -   high deductible consumer-driven health care plans this approach        includes health savings and retirement accounts that are        intended to shift the financial responsibility for purchasing        healthcare services to the plan member, thus incenting the plan        member to be healthier and a discriminating healthcare shopper;    -   disease management the plan sponsor hires nurses or coaches to        encourage patients with chronic conditions to be compliant with        recommended treatments;    -   population health management to disease management, but includes        other methods such as risk assessments, predictive modeling,        wellness and prevention to address the complete population, not        just chronically ill patients; value-base benefit design (VBBD)        or value-based insurance design (VBID)—designed to lower the        financial barriers to patients with chronic conditions or use        other financial incentives to encourage patient compliance.

In addition to the plan sponsor financially rewarding plan members forparticipation in these programs or for accomplishing health objectives,the other characteristic common to these approaches is that medicalservice providers are excluded from the arrangement or have only aperfunctory role.

In essence, there have been two movements attempting to meet thechallenge making universal healthcare coverage affordable one in whichplan sponsors financially incent medical service providers (serviceproviders and healthcare service providers) to change their practiceperformance to the exclusion of the patient, and another in which theplan sponsor financial incents patients to improve their healthbehaviors to the exclusion of the medical service provider. Afterdecades of effort and countless attempts, neither of these movements hassucceeded in meeting the challenge.

In 2010, the federal government passed the Patient Protection andAffordable Care Act (PPACA or ACA) for the principal purpose of reducingthe number of uninsured Americans. A secondary purpose of the law is tomake healthcare less expensive to the country can afford to provideuniversal coverage. The PPACA's affordability provisions are primarilyfocused on improving the efficiency and effectiveness of the country'shealthcare delivery system. Essentially nothing in the law addresses howto incent Americans to improve their health habits to prevent andreverse preventable conditions such as obesity. As a result, mostexperts agree that the law cannot effectively resolve healthcareaffordability. Therefore, the goal of universal coverage cannot beattained or sustained without either further crippling the U.S. economyor by rationing care to Americans.

So back to the challenge, how can a society such as the U.S. providehealthcare cover to its entire population when the country can'teffectively afford the cost of the current system with 17% of its peopleuninsured? How can people be attracted to the medical profession toalleviate the growing provider supply and demand issue when the economicoutlook for the profession seems so gloomy?

The current invention is directed to improving the delivery ofhealthcare and health behaviors by creating a system of incentives thatalign the interests of healthcare's essential stakeholders healthcareservice providers (principally physicians), healthcareconsumers/patients (health plan members), and health plan sponsors(health insurers, self-insured employers, health plans, and thegovernment's Medicare and Medicaid programs) in a win-win-winarrangement. Unlike other cost containment methods that haveconsistently failed to recognize or accommodate for this fundamentalsuccess criterion of stakeholder alignment, the present inventionprovides an effective system to controlling healthcare costs by“triangulating” the interests of the service provider, the patient andthe plan sponsor to improve the standard of care and encourage healthybehaviors, which leads to better health.

The present invention is directed to a method and information technologybased system for simultaneously controlling cost by improving thedelivery of healthcare related services by medical service providers andimproving the health behaviors and status of patients (health planmembers) by directing health plan sponsored financial rewards to boththe healthcare service provider and the patient for enhancingcommunication and co-decision-making between medical service providersand patients, increasing the knowledge of the patient about how toself-manage his or her health, providing a system of “checks andbalances” to measure and motivate patient and medical service provideradherence to accepted performance standards. As used herein the term“information technology based” means telephonic. Internet, web-based, orother computer based system for recording, storing, processing andcommunicating information.

SUMMARY OF THE INVENTION

The present invention is directed to a method for improving the deliveryof healthcare services and the promotion of healthy behaviors,simultaneous. The method comprises receiving a diagnosed healthcondition of a patient and a claim for services rendered from a serviceprovider. A service provider performance standard is sent to the serviceprovider based on the received diagnosed health condition. The serviceprovider is queried to generate a service provider declaration ofadherence or a reason for non-adherence to the service providerperformance standard and a service provider agreement to allow or anacknowledgment that the patient to confirm or rate the service providerdeclaration of adherence or reason for non-adherence. The diagnosedhealth condition, the service provider performance standard, the serviceprovider declaration of adherence or the reason for non-adherence, and apatient performance standard are transmitted to the patient. The patientis queried to generate a patient demonstration of knowledge of thediagnosed health condition, a patient declaration of adherence or reasonfor non-adherence to a patient performance standard, and a patientagreement to allow the service provider to confirm or acknowledge thepatient demonstration of knowledge and the patient declaration ofadherence or reason for non-adherence to the patient performancestandard. The patient demonstration of knowledge, the declaration ofpatient adherence or reason for non-adherence to the patient performancestandard are transmitted or made available to the service provider. Theservice provider is queried to generate a service provider confirmationof the patient demonstration of knowledge and the declaration of patientadherence or the reason for non-adherence to the patient performancestandard. The patient is queried to generate a patient confirmation ofthe service provider declaration of adherence or reason fornon-adherence to the service provider performance standard. The serviceprovider confirmation, the patient confirmation, the service providerdeclaration of adherence or reason for non-adherence, and the patientdemonstration of knowledge, patient declaration of adherence or reasonfor non-adherence are authenticated and payment of the claim forservices rendered and disbursement of a performance-based incentive tothe service provider and a performance-based incentive to the serviceprovider are authorized based on authentication.

The present invention is further directed to an information technologybased, such as a web-based or telephonic method, for managing healthcaredelivery and for promoting healthy behavior. The method comprisesreceiving a patient identification and at least one diagnosis from aservice provider through a web or telephonic interface. The methodfurther includes transmitting a service provider performance standard, apatient performance standard and patient educational articles to theservice provider corresponding with each diagnosis received from theservice provider through the web or telephonic interface. A serviceprovider declaration of adherence to the service provider performancestandard or a reason for non-adherence is received from the serviceprovider. An information therapy prescription of one or more patienteducational articles, a prescription of the patient performancestandard, and a rating of patient adherence to a patient performancestandard are received from the service provider. Authorization from theservice provider to allow the patient to verify or rate the serviceprovider declaration of adherence to the performance standard or toexpress an opinion about the reason for non-adherence, and to have theservice provider declaration of adherence to the service providerperformance standard or the reason for non-adherence that authenticatedand adjudicated. Disbursement of a performance-based incentive to theservice provider based upon verification by the patient andauthentication and adjudication of the service provider declaration ofadherence or the reason for non-adherence to the performance dr d isoccurs upon receipt of verification by patient.

The present invention further includes a system for managing healthcaredelivery and for promoting healthy behaviors. The system comprises ahealthcare services provider web-based or telephonic interface, apatient web-based or telephonic interface, and a means to automaticallyauthenticating and adjudicating. The healthcare services providerweb-based or telephonic interface is adapted to accept a patientidentification and a diagnosis from a healthcare services provider, totransmit a healthcare service provider performance standard, ahealthcare service provider agreement to allow the patient to confirm orrate the healthcare service provider declaration of adherence or thehealthcare provider reason for non-adherence to the healthcare providerperformance standard, a patient performance standard, and patienteducational articles to the healthcare services provider based upon thediagnosis, to accept a healthcare service provider declaration ofadherence or reason for non-adherence to the healthcare service providerperformance standard, optionally to accept an after-the-fact healthcareservice provider rating of patient adherence to the patient performancestandard, to accept a healthcare service provider information therapyprescription of one or more of the patient educational articles to thepatient, and to accept healthcare service provider verification of apatient declaration of adherence to the patient performance standard.The patient web-based or telephonic interface is adapted to provide thepatient with the healthcare service provider performance standard, thepatient performance standard, the information therapy prescription, anda patient agreement to allow the service provider to confirm or rate apatient declaration of adherence or reason for non-adherence to thepatient performance standard and a patient answer to a query regardingthe information therapy prescription, to provide at least one query tothe patient regarding the information therapy and the patientperformance toward, to receive at least one answer to the at least onequery regarding the information therapy and the agreement to allow theservice provider to confirm or rate the patient declaration of adherenceor reason for non-adherence to the patient performance standard and thepatient answer to the query regard the information therapy prescription,to accept the patient declaration of adherence or reason fornon-adherence to the patient performance standard, to accept the patientagreement answer to allow the service provider to confirm or rate thepatient declaration of adherence or reason for non-adherence to thepatient performance standard and the patient answer to the query regardthe information therapy prescription, to accept a patient verificationof the service provider declaration of adherence or reason fornon-adherence to the service provider performance standard. The meansfor automatically adjudicating and authenticating the service providerdeclaration of adherence, the patient declaration of adherence, theservice provider agreement to allow the patient to confirm or rate theservice provider, the patient agreement to allow the service provider toconfirm or rate the patient, the patient verification of the healthcareservice provider declaration of adherence, and the healthcare serviceprovider verification of the patient declaration of adherence; forproviding an authorization for disbursement of a performance-basedreward to the patient and a performance-based reward to the servicesprovides upon adjudication and authentication.

BRIEF DESCRIPTION OF THE FIGURES.

FIGS. 1 and 1A are a flow chart representing the medical practitioner's(service provider's) portion of one embodiment of the Program.

FIGS. 2 and 2A are a flow chart representing the patient's portion ofone embodiment of the Program.

FIG. 3 is a diagrammatic illustration of an Information Therapy (Ix)Program embodiment of the method of the present invention.

FIG. 4 is an illustrative representation of a webpage used in the methodand system of the present invention.

FIG. 5 is an illustrative representation of a webpage used in the methodof the present invention. The webpage shown represents a step in themethod of accepting a patient's member ID or last name.

FIG. 6 is a representative webpage interface used to accept a diagnosisfrom a service provider,

FIG. 7 is an illustrative webpage interface that may be used in thepresent invention. The webpage of FIG. 7 is adapted to accept multiplediagnoses from a service provider, if necessary.

FIG. 8A is a webpage interface designed to guide the service providerthrough the performance-based standards for a selected diagnosis.

FIG. 8B is an alternative webpage interface designed to guide theservice provider through the performance-based standards for a selecteddiagnosis.

FIG. 9A is an exemplary webpage of the present invention illustratingthe interactive nature of the present invention by showing a menu ofreasons for non-adherence upon deviation from the performance standard.

FIG. 9B is an alternative exemplary webpage of the present inventionillustrating the interactive nature of the present invention by showinga menu of reasons for service provider non-adherence upon deviation fromthe performance standard.

FIG. 9C is an exemplary information therapy prescription webpage.

FIG. 10 shows an initial “welcome page” on a patient side of the presentmethod,

FIG. 11 an interim webpage used to provide the patient with healthinformation about his/her diagnosis including EBM treatments,recommended care, health maintenance, and/or other performancestandards.

FIG. 12A illustrates an exemplary webpage comprising a questionnaireused to allow the patient to indicate his/her knowledge or understandingof the health information provided by the webpage shown in FIG. 11,

FIG. 12B is an exemplary webpage showing the patient's options aftergiving an incorrect answer to a web-based test used to test thepatient's knowledge of the information therapy prescribed by the serviceprovider.

FIG. 13 is an exemplary webpage showing an inquiry of the patient toshare the patient's opinion as to how closely he or she is followinghealth recommendations.

FIG. 14 is an exemplary webpage used to allow the patient to authorizerelease of the patient's responses to an information therapyquestionnaire to the patient's service provider.

FIG. 15 is an exemplary webpage used by the patient to rate his or herservice provider.

FIG. 16 is an exemplary voucher used to notify the patient they havecompleted the information therapy process and earned a financial reward.

DESCRIPTION OF THE PREFERRED EMBODIMENTS

The current invention is often referred to as a healthcare“pay-for-perthrmance” or “P4P” program. Most P4P programs exclusivelyreward or motivate medical providers (doctors and hospitals). Thecurrent invention rewards both the medical provider and the patient“interactively” in a manner that creates a simultaneous benefit to theservice provider, the patient, and the purchaser/payer (health plan).The current invention may preferably be described as an “alignment ofinterest” or “AOI” program because it aligns the interest of the medicalprovider, the patient and the health plan sponsor in a “win-win-winarrangement.

The current invention typically involves four (4) parties: the medicalservice provider or practitioner (doctors); the patient (consumer orhealth plan member); the party who underwrites the cost or risk of thehealthcare (purchaser or payer or employer or insurer or government orhealth plan or health plan sponsor); and the independent operator of theinvention (referred to as an intermediary or “Informediary”)

The current invention also comprises the following elements: aperformance standard (or set of performance standards) for both themedical provider and the patient that have been shown (preferably by anindependent and credible third party) to be effective at improvinghealthcare and health in a manner that controls healthcare costs;performance-based incentives that may comprise financial rewards paid bythe health plan to the medical provider and patient; a web-based ortelephonic system of checks and balances that asks the medical providerand the patient to independently and individually declare adherence orprovide a reason for non-adherence to the respective performancestandard, asks the medical provider and the patient to independently andindividually agree to allow the other party to confirm his/herdeclaration of adherence or reason for non-adherence, and further asksthe service provider and patient to independently and individuallyconfirm each other's declaration of adherence or reason fornon-adherence; and a website (Website) operated by the Informediary thatcomprises a set of proprietary Internet applications that facilitatesthe system of checks and balances.

In the current invention, the health plan disburses performance-basedfinancial rewards independently to the medical provider and patient whenthe Informediary authenticates that the medical provider and/or thepatient have accessed the Website, demonstrated or gained. knowledgeabout the respective performance standards, declared adherence orprovided a reason for non-adherence to the performance standards, agreedto allow the other party to confirm his/her declaration of adherence orreason for non-adherence, and confirmed (or denied) the adherence to theperformance standard by the other party.

The current invention is designed to “bolt on” to health plans(including plans sponsored by health insurers, the government's Medicareand Medicaid programs, and self-insured employers) to improve health andhealthcare in a manner that leads to healthcare cost containment. Insome respects, the current invention creates a platform by which athree-way contract or partnership can be established between the healthplan, healthcare service providers and patients, which is administeredby the intermediary. Accordingly, health plans are potential customersof the current invention, while healthcare service providers andpatients are users. Other terms used to describe the result achieved bythe current invention include: “triangulation” and “triangulation toreach a state of equilibrium;” “mutual accountability,” “mutualaccountability partnership,” and “doctor-patient mutual accountability.”

The Information Therapy (Ix) Program provided by the current inventiondirects the health plan to financially reward healthcare serviceproviders medical practitioners) and patients “interactively” forcontrolling healthcare costs and utilization through the incorporationof evidence-based medicine treatment guidelines, information therapy,best clinical practices, and healthy behaviors, which are collectivelyreferred to as performance standards of the Ix Program. The currentinvention is delivered through a proprietary Internet Website wheredoctors (medical practitioners) and patients read pertinent medicalcontent and respond to a series of questions to determine, declare,acknowledge, confirm, and motivate compliance to performance standardsthat have been shown to improve the standard of care and the level ofhealth, which in turn, lead to lower healthcare costs. The invention isintended to compliment other quality improvement and cost containmentmethods and initiatives such as: disease management; consumer-drivenhealthcare; accountable care organizations (ACOs); patient centeredmedical homes (PCMHs); population health management including healthrisk assessment, readiness to change, health screenings, wellnessexaminations, wellness and fitness programs, smoking cessation,predictive modeling; medical malpractice risk management; the adoptionof personal health records (PHRs), recommended hospital care managementprograms; pre-authorization certification of expensive procedures andtests; pharmacy benefit management including electronic prescribing,therapeutic substitutions, and drug interaction; electronic healthmonitoring devices; and the adoption of electronic health (medical)record (EHR) systems and the related meaningful use criteria.

Rewarding medical practitioners (physicians and hospitals) in thisfashion is commonly referred to as “pay-for-performance” or “P4P.” It isalso referred to as “value-based” healthcare, in contrast to“volume-based” healthcare. However, the current invention's incentivesystem is unlike any other P4P program in that financial rewards arepaid by the health plan (healthcare purchaser/payer) to both the medicalprovider (practitioner) and the patient for voluntarily, individuallyand independently (or dependently) declaring (or demonstrating)compliance to performance standards (that are known to improve healthand healthcare that leads to reduced utilization and cost of healthcareservices) through the invention's Website, and also for agreeing toallow the other party to individually and independently confirm (verifyor acknowledge) each other's (his/her) declaration (or demonstration) ofadherence to performance standards through the Website. In effect, thecurrent invention directs health plan sponsored financial rewards toboth medical practitioners and patients to invoke powerful psychosocialmotivators inherent to the doctor-patient relationship by asking themedical practitioner and the patient to voluntarily serve as eachother's “judge and jury” as to the other person's adherence toperformance standards known to improve health and healthcare. The innatedesire by both the medical practitioner and patient to please oneanother augments the financial incentives to increase adherence to theperformance. Since the invention is accomplished through a proprietaryInternet Website that allows for an independent third party or a healthplan to authenticate and report the medical practitioner and patient's“declarations and confirmations”, a natural check and balance (mutualaccountability) is created that serves as a very effective and efficientmeans (incentive) to shape the behaviors of the medical practitioner(provider) and the patient, which again, is above and beyond theinvention's financial rewards. This process of “declare and confirm” and“demonstrate and acknowledge” create “checks and balances” that definesthe terms “doctor-patient mutual accountability” and “interactive”rewards and incentives. In the present invention, the interests of themedical practitioner (provider), the patient and the health plan(purchaser/payer) are aligned in a “win-win-win” arrangement that definethe terms “triangulation to reach a state of equilibrium” and “mutualaccountability partnership.”

More specifically, medical practitioners “win” by being compensated forrendering a higher standard of care, by earning the admiration of theirpatients, by enhancing their reputation and image with their peers, andby the personal satisfaction of providing superior care to theirpatients. Patients “win” by earning financial rewards for demonstratingknowledge of and compliance to healthy behaviors and rating theirmedical practitioner's performance; by gaining knowledge, empowermentand motivation to self-manage their health; by attaining the peace ofmind that their medical practitioners are rendering recommended EBMcare; and by achieving the satisfaction that their doctor is aware oftheir health literacy and adherence to the performance standard. Healthplans “win” by gaining a means to better insure that they are receivinggreater value for their healthcare purchases, plus a means to adjustboth the size and nature of the rewards and performance standards toimprove healthcare and healthiness to achieve cost savings that producea return on investment. Because of its unique aligning feature, theinvention could be described as an “alignment of interest” or “AOI”program as opposed to a P4P program.

The current invention provides an I_(x) (Ix) Program model that rewardsservice providers (medical practitioners) financially and in other wayswhen they adhere or provide a reason for non-adherence to a performancestandard such as considering an EBM treatment guidelines, prescribingI_(x) to their patients, and agreeing to allow their patients to confirmor rate their adherence or reason for non-adherence to the performancestandard through a medical practitioner Internet Website application.The rewards, however, may comprise financial rewards or other rewardslimited in their type and nature by the imagination of the health plancustomer of the current invention. The same holds true for performancestandards. In addition to EBM treatment guidelines and Ix prescriptions,a medical practitioner performance standard could also be any servicethat is independently judged and validated to be beneficial to thepatient that can be structured interactively through the invention'sWebsite. Examples of these types of performance standards include:patient-integrated pre-authorization certification of expensive medicalservices; patient-integrated hospital care management systems; drugtherapy (pharmacy benefit) management programs including e-prescription,therapeutic drug substitution, automated drug interactions, and patientpharmacy education with knowledge verification; the adoption and use ofpersonal health records; medical education programs; wellness andfitness programs; social networking therapy programs; health riskassessments; readiness to change interventions; compliance torecommended treatments; use of automatic health monitoring devices;hospitalization pre-admit and discharge education and adherenceprograms; provider quality and cost education and transparency; andadoption of health self-management programs. In effect, the health plancan choose a specific health objective, such as prenatal care withself-management testing that is confirmed by a licensed obstetrician(who is compensated for the extra time and liability). Then the healthplan can specify an extra amount of financial rewards, such as $200 forpatient adherence against this performance standard, whereas a normalpatient financial reward may be $25. The health plan's objective is toprevent health problems for the mother and child, and the associatedcosts by using both a financial reward and the psychosocial motivatorsinherent to the doctor-patient relationship. This process illustratesjust one of countless ways a health plan can use the invention to targeta specific health or cost objective, it is referred to a“precision-guided rewards and performance standards.”

In the Ix program model of the current invention, the process of aservice provider, such as a medical practitioner, physician, doctor,clinician, chiropractor, nurse, dentist, or other health care serviceprovider, accessing the Website to “practice the method” (Ix Program orProgram) by considering EBM, prescribing Ix, and agreeing to allow thepatient to confirm/rate the doctor's performance can be initiated as aresult of the doctor's normal insurance claim tiling. The receipt of aclaim for an applicable service, such as a patient office visit, promptsthe independent intermediary to send an email or fax notification to thedoctor. This “after-the-fact” notification directs the doctor to accessthe Website to “practice the Program,” In this example, when the doctorsuccessfully responds to the Website, the independent intermediarynotifies the health plan to compensate the doctor for practicing theProgram for the associated patient office visit. This implies that themethod facilitates timely and direct physician (service provider)compensation for each patient encounter on a per-occurrence-of-carebasis. This method of compensation is considered “Pavlovian” in thatphysicians receive quick rewards that are directly tied to theirperformance. Other incentive-based (P4P) programs that compensatephysicians in an indirect and untimely fashion, such as annual payments,are often based on formulas designed to measure a variety of performancecriteria and judged by a third party. Physicians find these types ofincentive-based programs objectionable, especially when compensation isbased on complicated formulas or dependent on patient performance orinvolve “cookbook medicine” or judge by third parties that physicians donot trust.

In a preferred embodiment of the current invention, doctors can initiatethe process during the patient office visit on a “real-time” basisthrough the medical practitioner (service provider) Internet Websiteapplication. The doctor's appropriate responses entered into the Websiteaffect an immediate information therapy prescription to the patient. Thedoctor's responses are stored in the independent intermediary's Websitedatabase. When the doctor files an insurance claim for an applicablemedical practitioner service (such as a patient office visit), the claimis forwarded (typically through the health plan's administrator byelectronic means) to the independent intermediary. The claim is thenlinked to the doctor's stored Website responses. The independentintermediary then notifies the health plan to compensate the doctor forpracticing the program for the associated patient office visit.

As described earlier, the current invention can also be initiated“after-that-fact” when the independent intermediary identifiesapplicable medical practitioner services from the tiling of a claim forreimbursement. This triggers an e-mail notification from the independentintermediary to the medical practitioner (doctor). The doctor respondsto the e-mail through the medical practitioner Website. The medicalpractitioners appropriate responses can affect an automatic payment orreimbursement increase to the medical practitioner (for practicing theProgram and an information therapy prescription to the patient.

When the patient receives the Ix prescription by mail or e-mail (orhanded to the patient during the encounter by the doctor), he/she isdirected to a patient Website. There the patient is asked to readevidence-based medical content and answer a series of questions. Thesequestions are designed to test the patients understanding of his/hercondition, the recommended treatments and healthy behaviors, and howbest to self-manage his/her condition. These questions also determinethe patient's adherence or reason for non-adherence to recommendedtreatment, agreement to allow his/her doctor to confirm/acknowledge/ratehis/her adherence or reason for non-adherence to the recommendedtreatments and healthy behaviors, and seek his/her impression of thedoctor's care relative to recommended care (treatments). As the patientanswers these questions, the patient scores points toward a financialreward or refund of the patient's out-of-pocket medical expenses. Thepatient's score and corresponding reward amount is automaticallytransmitted by the independent intermediary to the patient's healthplan, which makes the disbursement of a performance-based reward to thepatient. As used herein, “independent intermediary” may also include thepatient's health plan. In an alternative embodiment of this model of theinvention, the independent intermediary can disburse theperformance-based rewards to doctors and patients from funds supplied bythe health plan. The current invention provides for the automatic oroptional forwarding of the patient's actual responses by the independentintermediary through the Website to the patient's doctor to supportsubsequent care and as a means for the doctor to confirm/acknowledge thepatients declaration or demonstration of adherence to a performancestandard. Alternatively, the intermediary can post the patient'sresponses on a secured section of the Website for the doctor to accessfor follow-up and confirmation purposes.

The current invention has a number of built-in features that aredesigned to achieve service provider (doctor) and patient acceptance.One of these features addresses concerns doctors have about being forcedto practice “cookbook medicine.” The current invention allows and, infact, encourages service providers (medicalpractitioners/doctors/physicians/clinicians/healthcare or medicalservice providers) to deviate from treatment guidelines when it isappropriate in their judgment. The service provider Website offers thedoctor a menu of reasons to deviate or the doctor can briefly describe areason for non-adherence, provided the doctor agrees to allow thepatient to review/concur with the reason for deviation/non-adherence.When the doctor provides a reason for deviating from (non-adherence to)a guideline, the intermediary stores that reason in the Website databaseto be presented to the patient later in the process. When the patientaccesses the Website (which is described below), one of the questionshe/she is asked to answer is to rate or express an opinion about thedoctor's reason for deviating from a guideline. As a result, the healthplan is served (wins) by this feature of the current invention becausethe doctor knows his/her reason for deviation (or for that matter,declaration of guideline adherence) will be rated/confirmed by thepatient, which may cause the patient's opinion of the doctor's care tobe reinforced—or diminished to the point the patient may refer thedoctor to others or seek care elsewhere. Doctors are aware that theirpatients are gaining valuable information through the Program anddoctors know that their patients will expect care that is aligned withevidence-based and/or recommended treatments, Doctors also become awarethat they are being rated by their patients against evidenced-based andrecommended care. Though this rating may or may not directly impact anindividual doctor's compensation on a per-occurrence-of-care basis, mostdoctors do not want their patients to think/learn they may be practicinginferior medicine, nor do doctors want their aggregate patient rating tocause them to be ranked poorly against their peers or to suffer negativeconsequences because a poor aggregate rating or a low ranking may bepublished. This check and balance aspect of the current invention servesas an important incentive to encourage doctors to be adherent toguidelines or to provide appropriate reasons for deviation from aguideline. Doctors are served (win) by this feature of the currentinvention because this check and balance feature alleviates the concernsmedical practitioners (doctors) have about being forced to practice“cookbook medicine” and helps doctors better communicate and educatetheir patients. Patients are served (win) because the Programcommunicates their doctor's reason for deviation so patients canunderstand that a particular guideline does not necessary fit a specificmedical condition. This feature also helps the developers of guidelinesand medical researchers determine which guidelines are strongest andwhich ones need further research and development.

Another feature of the current invention provides for the efficient andeffective dissemination of advancements in medicine to service providers(medical practitioners) and serves as a means (incentive system) toencourage doctors to adopt new and proven advancements in medicine. Thisfeature accomplishes these objectives by highlighting new advancementsin the decision-tree guidelines or medical content presented in themedical practitioner Website. The Website can require the medicalpractitioner to read the highlighted guideline or content that containsresearch studies or literature that supports the advancement. Themedical practitioner can also be required to answer a questionnaire orindicate an acknowledgement or take a test about the medical advancementin order for the medical practitioner to receive compensation and/or toearn the higher rates of reimbursement offered through the Program. Thesuccessful completion of the questionnaire or test may earn the medicalpractitioner credits toward required continuing medical education (CME).The current invention may also forward (electronically or otherwise) theresults of the questionnaire to the medical practitioner's licensureboard for accreditation purposes. Since the doctor is already asked todeclare adherence or provide a reason for non-adherence to theguideline, adoption of medical advancements can be accelerated.

Though the service provider and patient psychological incentives(psychosocial motivators inherent to the doctor-patient relationship)are interactive in that both parties are aware that they will be askedto judge/acknowledge each other's declaration/demonstration of adherence(or non-adherence) to performance standards against their actualperformance (adherence), the current invention ideally (but notnecessarily) separates the financial reward provided to the medicalpractitioner from the reward provided to the patient. Thus, the medicalpractitioner may be paid for his/her time and effort independent (ordependent) to how the medical practitioner's patients respond to theirIx or adherence (non-adherence) to a patient performance standard.Patients' performance-based rewards may also be independent (ordependent) of the medical practitioners' participation/adherence,prescribing information therapy or adherence to the medical practitionerperformance standards. In other words, the reward strategies involvingparticipant elections/Website choices of the current invention have beenpurposely configured to create a natural and beneficial check andbalance between doctors and the patients. This set of strategic checksand balances (“doctor-patient mutual accountability”) solves the issuesof compliance monitoring and appropriate provider deviation from aguideline that other incentive-based models cannot solve.

The current invention provides a method for delivering healthcareservices designed to tower healthcare costs by elevating the standard ofcare and encouraging patients to lead healthier lives through aweb-based/telephonic interface, provider-patient interactive incentive(reward) system. An application of the method comprises the steps ofreceiving a claim for compensation for medical services from a medicalpractitioner for medical treatment of a patient covered by theinvention's program. The claim includes at least one applicablediagnosis code corresponding to at least one applicable medicaltreatment (such as an office visit) rendered to patient. If at least onediagnosis code of the submitted claim corresponds to a medical diagnosisfound in a database of applicable medical diagnoses, then a notice issent by the independent intermediary, also known as an Informediary, tothe medical practitioner, directing the medical practitioner tovoluntarily access a Website operated by an informediary. The Websitepresents the medical practitioner with EBM treatment guidelines or otherpertinent medical content elating to the medical diagnosis of thepatient. In addition to rendering the common/recommended medicaltreatment, the medical practitioner prescribes Ix for said patient thatprovides the patient with instructions concerning managing the medicalcondition/diagnosis and living a healthy lifestyle. The medicalpractitioner may be given the opportunity to rate the patient'scompliance with the prescribed information therapy, recommendedtreatments, and instructions relating to a healthy lifestyle.

In another embodiment, the current invention provides a method fordelivering healthcare services through a web-based/telephonic interface,interactive provider-patient incentive (reward) system. One method ofthe current invention comprises the steps of the Informediary receivinga claim for compensation for medical services rendered by a medicalpractitioner to a patient covered by the Program of the currentinvention. The claim filed by the medical practitioner includes at leastone applicable diagnosis code corresponding to at least one applicablemedical treatment rendered to said patient. Upon receipt by theInformediary, the claim is examined to determine if at least onediagnosis code corresponds to an applicable medical diagnosis found in adatabase of applicable medical diagnoses. If a corresponding applicablemedical diagnosis is present, then a notice is sent by the Informediaryto the medical practitioner. The notice sent to the medical practitionerincludes the instructions necessary for accessing a medical practitionerWebsite. Once the medical practitioner gains access to the Website, themedical practitioner will have access to EBM treatment guidelines (ifone exists) relating to the medical diagnosis/diagnoses of the patient.Thereafter, the medical practitioner declares/demonstrates adherence orprovides a reason for non-adherence to the EBM treatment guideline (ifone exists), agrees to allow the patient to confirm/rate the medicalpractitioner's declaration/demonstration of adherence or reason fornon-adherence to the EBM treatment guideline, and then prescribeseducational material in the form of information therapy to the patientrelating to the medical diagnosis/diagnoses through the Websiteapplication. The prescribed information therapy includes instruction forthe patient to self-manage his/her medical condition, guidelines forhealthy behavior, and a means to assess/determine/test the patient'sunderstanding (health literacy) of the educational material.Additionally and alternatively, the medical practitioner rates patientadherence to the prescribed Ix and recommended treatments and healthybehaviors. Following the prescription of Ix, the Informediaryautomatically generates a notice to the patient directing the patient toaccess the Website. Once the patient accesses the Website, the Websiteprovides the patient with the means to access the educational materialrelating to his/her medical diagnosis/diagnoses. The method furtherprovides for the monitoring of the patient's access of the medicalinformation. The Website further provides a knowledgeexam/assessment/test designed to measure patient comprehension of themedical diagnosis, how his/her doctor (medical practitioner) should betreating the diagnosis, and how the patient can/should self-managehis/her condition. Provided that the patient takes the exam or declareshis/her understanding, the Website will automatically score theknowledge exam and it will provide the patient with the option of (orrequire) forwarding (posting for access) the knowledge exam ordeclaration of understanding results to the medical practitioner. Thepatient is also asked to indicate their personal adherence or reason fornon-adherence to recommended care and healthy behaviors, to report theirhealth status, to agree to allow his/her medical practitioner toconfirm/rate/acknowledge the patient's knowledge exam/declaration anddeclaration/demonstration of adherence (or reason for non-adherence) torecommended care and healthy behaviors, and to rate their medicalpractitioner's performance against the recommended care. Finally, thepatient is provided with the option of authorizing the compliance ratingassigned by his/her medical practitioner to the patient's health planand/or employer for the purpose of determining a financial or othertypes of reward.

In a further embodiment of the current invention, the patient isprovided with the option of rating (or is required to rate) the medicalpractitioner's adherence or reason for non-adherence to EBM treatmentguidelines or other accepted care corresponding to the patient'sdiagnosis. Following review of the prescribed Ix educational material,the patient is asked to rate the medical practitioner's care against theIx educational material. This rating ideally does not, though it may,directly affect that medical practitioner's reward or compensation on acase-by-case basis. However, it does begin to build an overall clinicalperformance rating for that medical practitioner. This can be used tohelp individual medical practitioners measure their performance againsttheir peers. Poor ratings can be used in peer review. This embodiment ofthe invention allows and encourages medical practitioners the freedom touse their clinical judgment to deviate from a guideline while receivingthe maximum financial reward, provided the medical practitioner selectsor supplies a reason for the deviation and agrees to allow the patientto concur with/acknowledge/rate the medical practitioner's reason fornon-adherence. Preferably, the ratings provided by the medicalpractitioner and the patient would be obscured from each other to helpprotect the doctor-patient relationship with each party having theoption of releasing his/her rating to the other party.

Still further, the current invention provides a method for deliveringhealthcare services through a web-based/telephonic interface,interactive provider-patient incentive (reward) system. The system ofthe current invention comprises a Website operated by an Informediaryand having a medical practitioner portion/section and a patientportion/section. The medical practitioner's portion is programmed to beaccessed directly by the medical practitioner during the patientencounter (the “real-time” method) or to receive a claim submitted bythe medical practitioner after the patient encounter containing standardcodes for the patient's diagnosis(es) and medical services rendered bythe medical practitioner (the “after-the-fact” method). The Websitecompares the medical diagnosis(es) entered by the medical practitionerdirectly into the Website during the patient encounter or from a codedclaim submitted by the medical practitioner to a database of medicaldiagnoses.

In the Ix program model of the current invention, the process of aservice provider accessing the Website to “practice the method” (IxProgram or Program) by considering EBM, prescribing Ix, and agreeing toallow the patient to confirm/rate the service provider's performance canbe initiated as a result of the doctor's normal insurance claim filing.The receipt of a claim for an applicable service, such as a patientoffice visit, prompts the independent intermediary to send an email orfax notification to the doctor. This “after-the-fact” notificationdirects the doctor to access the Website to “practice the Program.” Inthis example, when the doctor successfully responds to the Website, theindependent intermediary notifies the health plan to compensate thedoctor for practicing the Program for the associated patient officevisit. This implies that the method facilitates timely and directphysician (service provider) compensation for each patient encounter ona per-occurrence-of-care basis. This method of compensation isconsidered “Pavlovian” in that physicians receive quick rewards that aredirectly tied to their performance. Other incentive-based (P4P) programsthat compensate physicians in an indirect and untimely fashion, such asannual payments, are often based on formulas designed to measure avariety of performance criteria and judged by a third party. Physiciansfind these types of incentive-based programs objectionable, especiallywhen compensation is based on complicated formulas or dependent onpatient performance or involve “cookbook medicine” or judge by thirdparties that physicians do not trust.

In a preferred embodiment of the current invention, doctors can initiatethe process during the patient office visit on a “real-time” basisthrough the medical practitioner (service provider) Internet Websiteapplication. The doctor's appropriate responses entered into the Websiteaffect an immediate information therapy prescription to the patient. Thedoctor's responses are stored in the independent intermediary's Websitedatabase. When the doctor files an insurance claim for an applicablemedical practitioner service (such as a patient office visit), the claimis forwarded (typically through the health plan's administrator byelectronic means) to the independent intermediary. The claim is thenlinked to the doctor's stored Website responses. The independentintermediary then notifies the health plan to compensate the doctor forpracticing the program for the associated patient office visit

As described earlier, the current invention can also be initiated“after-that-fact” when the independent intermediary identifiesapplicable medical practitioner services from the filing of a claim forreimbursement. This triggers an e-mail notification from the independentintermediary to the medical practitioner (doctor). The doctor respondsto the e-mail through the medical practitioner Website. The medicalpractitioners appropriate responses can affect an automatic payment orreimbursement increase to the medical practitioner for practicing theProgram) and an information therapy prescription to the patient.

When the patient receives the Ix prescription by mail or e-mail (orhanded to the patient during the encounter by the doctor), he/she isdirected to a patient Website. There the patient is asked to readevidence-based medical content and answer a series of questions. Thesequestions are designed to test the patient's understanding of his/hercondition, the recommended treatments and healthy behaviors, and howbest to self-manage his/her condition. These questions also determinethe patient's adherence or reason for non-adherence to recommendedtreatment, agreement to allow his/her doctor to confirm/acknowledge/ratehis/her adherence or reason for non-adherence to the recommendedtreatments and healthy behaviors, and seek his/her impression of thedoctor's care relative to recommended care (treatments). As the patientanswers these questions, the patient scores points toward a financialreward or refund of the patient's out-of-pocket medical expenses. Thepatient's score is automatically forwarded by the independentintermediary to the patient's health plan, which makes the disbursementof a performance-based reward to the patient. In an alternativeembodiment of this model of the invention, the independent intermediarycan disburse the performance-based rewards to doctors and patients fromfunds supplied by the health plan. The current invention provides forthe automatic or optional forwarding of the patient's actual responsesby the independent intermediary through the Website to the patient'sdoctor to support subsequent care and as a means for the doctor toconfirm/acknowledge the patient's declaration or demonstration ofadherence to a performance standard. Alternatively, the intermediary canpost the patient's responses on a secured section of the Website for thedoctor to access for follow-up and confirmation purposes,

The current invention has a number of built-in features that aredesigned to achieve service provider (doctor) and patient acceptance.One of these features addresses concerns doctors have about being forcedto practice “cookbook medicine.” The current invention allows and, infact, encourages service providers (medicalpractitioners/doctors/physicians/clinicians/healthcare or medicalservice providers) to deviate from treatment guidelines when it isappropriate in their judgment. The service provider Website offers thedoctor a menu of reasons to deviate or the doctor can briefly describe areason for non-adherence, provided the doctor agrees to allow thepatient to review/concur with the reason for deviation/non-adherence.When the doctor provides a reason for deviating from (non-adherence to)a guideline, the intermediary stores that reason in the Website databaseto be presented to the patient later in the process. When the patientaccesses the Website (which is described below), one of the questionshe/she is asked to answer is to rate or express an opinion about thedoctor's reason for deviating from a guideline. As a result, the healthplan is served (wins) by this feature of the current invention becausethe doctor knows his/her reason for deviation (or for that matter,declaration of guideline adherence) wilt be rated/confirmed by thepatient, which may cause the patient's opinion of the doctor's care tobe reinforced—or diminished to the point the patient may refer thedoctor to others or seek care elsewhere. Doctors are aware that theirpatients are gaining valuable information through the Program anddoctors know that their patients will expect care that is aligned withevidence-based and/or recommended treatments. Doctors also become awarethat they are being rated by their patients against evidenced-based andrecommended care. Though this rating may or may not directly impact anindividual doctor's compensation on aper-occurrence-of-care basis, mostdoctors do not want their patients to think/team they may be practicinginferior medicine, nor do doctors want their aggregate patient rating tocause them to be ranked poorly against their peers or to suffer negativeconsequences because a poor aggregate rating or a low ranking may bepublished. This check and balance aspect of the current invention servesas an important incentive to encourage doctors to be adherent toguidelines or to provide appropriate reasons for deviation from aguideline. Doctors are served (win) by this feature of the currentinvention because this check and balance feature alleviates the concernsmedical practitioners (doctors) have about being forced to practice“cookbook medicine” and helps doctors better communicate and educatetheir patients. Patients are served (win) because the Programcommunicates their doctor's reason for deviation so patients canunderstand that a particular guideline does not necessary fit a specificmedical condition. This feature also helps the developers of guidelinesand medical researchers determine which guidelines are strongest andwhich ones need further research and development.

Another feature of the current invention provides for the efficient andeffective dissemination of advancements in medicine to service providers(medical practitioners) and serves as a means (incentive system) toencourage doctors to adopt new and proven advancements in medicine. Thisfeature accomplishes these objectives by highlighting new advancementsin the decision-tree guidelines or medical content presented in themedical practitioner Website. The Website can require the medicalpractitioner to read the highlighted guideline or content that containsresearch studies or literature that supports the advancement. Themedical practitioner can also be required to answer a questionnaire orindicate an acknowledgement or take a test about the medical advancementin order for the medical practitioner to receive compensation and/or toearn the higher rates of reimbursement offered through the Program. Thesuccessful completion of the questionnaire or test may earn the medicalpractitioner credits toward required continuing medical education (CME).The current invention may also forward (electronically or otherwise) theresults of the questionnaire to the medical practitioner's licensureboard for accreditation purposes. Since the doctor is already asked todeclare adherence or provide a reason for non-adherence to theguideline, adoption of medical advancements can be accelerated.

Though the service provider and patient psychological incentives(psychosocial motivators inherent to the doctor-patient relationship)are interactive in that both parties are aware that they will be askedto judge/acknowledge each other's declaration/demonstration of adherence(or non-adherence) to performance standards against their actualperformance (adherence), the current invention ideally (but notnecessarily) separates the financial reward provided to the medicalpractitioner from the reward provided to the patient. Thus, the medicalpractitioner may be paid for his/her time and effort independent (ordependent) to how the medical practitioner's patients respond to theirIx or adherence (non-adherence) to a patient performance standard.Patients performance-based rewards may also be independent (ordependent) of the medical practitioners' participation/adherence,prescribing information therapy or adherence to the medical practitionerperformance standards. In other words, the reward strategies involvingparticipant elections/Website choices of the current invention have beenpurposely configured to create a natural and beneficial check andbalance between doctors and the patients. This set of strategic checksand balances (“doctor-patient mutual accountability”) solves the issuesof compliance monitoring and appropriate provider deviation from aguideline that other incentive-based models cannot solve.

The current invention provides a method for delivering healthcareservices designed to lower healthcare costs by elevating the standard ofcare and encouraging patients to lead healthier lives through aweb-based/telephonic interface, provider-patienteractive incentive(reward) system. An application of the method comprises the steps ofreceiving a claim for compensation for medical services from a medicalpractitioner for medical treatment of a patient covered by theinvention's program. The claim includes at least one applicablediagnosis code corresponding to at least one applicable medicaltreatment (such as an office visit) rendered to patient. If at least onediagnosis code of the submitted claim corresponds to a medical diagnosisfound in a database of applicable medical diagnoses, then a notice issent by the independent intermediary, also known as an Informediary, tothe medical practitioner, directing the medical practitioner tovoluntarily access a Website operated by an Informediary. The Websitepresents the medical practitioner with EBM treatment guidelines or otherpertinent medical content relating to the medical diagnosis of thepatient. In addition to rendering the common/recommended medicaltreatment, the medical practitioner prescribes Ix for said patient thatprovides the patient with instructions concerning managing the medicalcondition/diagnosis and living a healthy lifestyle. The medicalpractitioner may be given the opportunity to rate the patientscompliance with the prescribed information therapy, recommendedtreatments, and instructions relating to a healthy lifestyle,

In another embodiment, the current invention provides a method fordelivering healthcare services through a web-based/tetephonic interface,interactive provider-patient incentive (reward) system. One method ofthe current invention comprises the steps of the Informediary receivinga claim for compensation for medical services rendered by a medicalpractitioner to a patient covered by the Program of the currentinvention. The claim filed by the medical practitioner includes at leastone applicable diagnosis code corresponding to at least one applicablemedical treatment rendered to said patient. Upon receipt by theInformediary, the claim is examined to determine if at least onediagnosis code corresponds to an applicable medical diagnosis found in adatabase of applicable medical diagnoses. If a corresponding applicablemedical diagnosis is present, then a notice is sent by the Informediaryto the medical practitioner. The notice sent to the medical practitionerincludes the instructions necessary for accessing a medical practitionerWebsite. Once the medical practitioner gains access to the Website, themedical practitioner will have access to EBM treatment guidelines (ifone exists) relating to the medical diagnosis/diagnoses of the patient.Thereafter, the medical practitioner declares/demonstrates adherence orprovides a reason for non-adherence to the EBM treatment guideline (ifone exists), agrees to allow the patient to confirm/rate the medicalpractitioner's declaration/demonstration of adherence or reason fornon-adherence to the EBM treatment guideline, and then prescribeseducational material in the form of information therapy to the patientrelating to the medical diagnosis/diagnoses through the Websiteapplication. The prescribed information therapy includes instruction forthe patient to self-manage his/her medical condition, guidelines forhealthy behavior, and a means to assess/determine/test the patient'sunderstanding (health literacy) of the educational material.Additionally and alternatively, the medical practitioner rates patientadherence to the prescribed Ix and recommended treatments and healthybehaviors. Following the prescription of Ix, the Informediaryautomatically generates a notice to the patient directing the patient toaccess the Website. Once the patient accesses the Website, the Websiteprovides the patient with the means to access the educational materialrelating to his/her medical diagnosis/diagnoses. The method furtherprovides for the monitoring of the patient's access of the medicalinformation. The Website further provides a knowledgeexam/assessment/test designed to measure patient comprehension of themedical diagnosis, how his/her doctor (medical practitioner) should betreating the diagnosis, and how the patient can/should self-managehis/her condition. Provided that the patient takes the exam or declareshis/her understanding, the Website will automatically score theknowledge exam and it will provide the patient with the option of (orrequire) forwarding (posting for access) the knowledge exam ordeclaration of understanding results to the medical practitioner. Thepatient is also asked to indicate their personal adherence or reason fornon-adherence to recommended care and healthy behaviors, to report theirhealth status, to agree to allow his/her medical practitioner toconfirm/rate/acknowledge the patient's knowledge exam/declaration anddeclaration/demolation of adherence (or reason for non-adherence) torecommended care and healthy behaviors, and to rate their medicalpractitioner's performance against the recommended care. Finally, thepatient is provided with the option of authorizing the compliance ratingassigned by his/her medical practitioner to the patient's health planand/or employer for the purpose of determining a financial or othertypes of reward.

In a further embodiment of the current invention, the patient isprovided with the option of rating (or is required to rate) the medicalpractitioner's adherence or reason for non-adherence to EBM treatmentguidelines or other accepted care corresponding to the patient'sdiagnosis. Following review of the prescribed Ix educational material,the patient is asked to rate the medical practitioner's care against theIx educational material. This rating ideally does not, though it may,directly affect that medical practitioner's reward or compensation on acase-by-case basis. However, it does begin to build an overall clinicalperformance rating for that medical practitioner. This can be used tohelp individual medical practitioners measure their performance againsttheir peers. Poor ratings can be used in peer review. This embodiment ofthe invention allows and encourages medical practitioners the freedom touse their clinical judgment to deviate from a guideline while receivingthe maximum financial reward, provided the medical practitioner selectsor supplies a reason for the deviation and agrees to allow the patientto concur with/acknowledge/rate the medical practitioner's reason fornon-adherence. Preferably, the ratings provided by the medicalpractitioner and the patient would be obscured from each other to helpprotect the doctor-patient relationship with each party having theoption of releasing his/her rating to the other party.

Still further, the current invention provides a method for deliveringhealthcare services through a web-based/telephonic interface,interactive provider-patient incentive (reward) system. The system ofthe current invention comprises a Website operated by an Informediaryand having a medical practitioner portion/section and a patientportion/section. The medical practitioners portion is programmed to beaccessed directly by the medical practitioner during the patientencounter (t)e “real-time” method) or to receive a claim submitted bythe medical practitioner after the patient encounter containing standardcodes for the patient's diagnosis(es) and medical services rendered bythe medical practitioner (t)e “after-the-fact” method). The Websitecompares the medical diagnosis(es) entered by the medical practitionerdirectly into the Website during the patient encounter or from a codedclaim submitted by the medical practitioner to a database of medicaldiagnoses.

Preferably, the system of the current invention will provide suitableincentives to both the patient and the medical provider to bring about achange in behaviors resulting in an improved standard of care and animproved level of healthiness that leads to better clinical outcomes forthe patient and lower overall costs for the healthcare system.Additionally, the improved method for delivering healthcare aligns theinterests of all the key stakeholders in the healthcare industry. Thesekey stakeholders are generally identified as medical providers(physicians/doctors/healthcare or medical service providers/medicalpractitioners/clinicians/providers/hospitals), patients (healthcareconsumers/heaith plan members/beneficiaries), and health plans(self-insured employers/health insurance companies/govemmental healthprograms such as Medicare, Medicaid, Veterans Administration, and IndianHealth Service/health plan sponsors). For the purposes of thisdiscussion, the current invention focuses on services delivered by amedical practitioner such as a physician; however, the methods of thecurrent invention apply equally well to other types of clinicians suchas physician assistants (PAs), nurse practitioners (NPs) and otherhealthcare providers recognized by patients as trusted and respectedhealthcare authorities.

To encourage medical practitioner participation in the method of thecurrent invention, medical practitioners will be financially rewarded(compensated) for each patient encounter when the medical practitioneraccomplishes the following tasks for each treated diagnosis: 1) ifavailable, consider EBM and other recommended treatment guidelines (andother performance standards) and indicate adherence or reason fornon-adherence to the guideline; 2) prescribe educational material in theform of information therapy to their patient (not optional for afinancial reward); 3) rate/acknowledge the patient compliance torecommended care for each diagnosis; 4) agree to allow the patientconfirm/rate the medical practitioners declaration of adherence orreason for non-adherence to the guideline or recommended care; 5)respond appropriately to patient responses on the Website to includewarnings/alerts of patient medical issues; and 6) congratulate thepatient for achieving health objectives.

As an encouragement to respond to Ix prescriptions and to live a healthylifestyle, the methods of the current invention financially rewardspatients for completing the following tasks: 1) read the medicaleducational material prescribed to them on the Website concerning theirhealth condition, recommended (EBM) care and other pertinent performancestandards; 2) answer questions presented on the Website to demonstratetheir understanding of the educational material; 3) indicate theiradherence or reason for non-adherence to the recommended (EBM) care andhealthy behaviors; 4) report (or have health monitoring devices report)their health stat s such as weight, blood pressure, blood sugar, andresting heart rate; 5) authorize access to pharmacy records to verifythat their prescriptions have been tilled and they have passed a drugliteracy assessment, and/or request verification that they havesuccessfully participated in a health assessment or screening program,and/or authorize access to lab and other test results, and/or authorizeaccess to a readiness to change program indicating their participationand accomplishments, and/or request verification that they have seen orscheduled to see a medical specialist or have successfully completed orscheduled to complete other recommended therapies, and/or releaseinformation indicating they have updated a personal health record withpertinent information and request his/her medical providers to use thepersonal health record in his/her treatment to achieve coordination ofcare and to prevent duplication of care, and/or provide access to anadvance directive, and/or participate in a pre-authorizationcertification of expensive tests and services (such as surgeries andhospitalizations) through the Website to prevent unnecessary proceduresand insure better clinical outcomes, and/or demonstrate/declare theirhealthy behavior or adherence by any other means to other performancestandards prescribed by their physician or offered by their health plan;6) agree to allow their medical practitioner to acknowledge/confirm/ratetheir adherence to any and all prescribed or offered performancestandards; 7) after acknowledging their medical practitioner's recordedresponses to the Website question(s) about adherence or reason fornon-adherence to a recommended treatment or performance standard, andtaking into consideration the educational material they have just readon the method's Website, rate/confirm/refute their medicalpractitioner's adherence or reason for non-adherence to the performancestandard; and/or 8) as an option, elect to have (authorize that) theirmedical practitioner's rating of the patient's adherence to recommendedcare and healthy behaviors (or other performance standards) be used todetermine their financial reward or health status (this election by thepatient further reinforces the Program's strategic checks and balances(“doctor-patient mutual accountability”) because patients are aware thatthis election will cause the Program to compare their personal healthadherence responses against their medical practitioner's rating of theirhealth compliance, and if the compliance indicators between the patientand the medical practitioner match, then the Program would indicate thatthe patient is be eligible for an additional financial reward from theirhealth plan).

In the preferred embodiment of the current invention, the intermediaryshould select the Program's treatment guidelines, educational material,and other types of medical practitioner and patient performancestandards, as well as the reason for non-adherence as an independentparty to prevent biasing the Program in favor of any of thestakeholders. With regard to the medical practitioner's reason fornon-adherence, the reasons must be appropriate/legitimate, and thereforethe reasons are established as the following:

-   -   Co-morbidity    -   Emergent condition    -   Pending lab or other test results    -   Contraindicated because: (requires the medical practitioner to        explain)    -   Using an advanced treatment with the patient's consent    -   Patient declines for financial reasons    -   Patient declines for other reasons: (requires the medical        practitioners to explain)    -   Guideline in error or out of date: (requires the medical        practitioners to explain)        The patient's reasons for non-adherence are established as:    -   I believe my doctor has mis-diagnosed my condition: (requires        the patient to explain and recommends the patient consult with        his/her physician)    -   I am afraid of the recommended treatments—(recommends the        patient consult with his/her physician)    -   I can't afford the recommended treates (recommends the patient        consult with his/her physician)    -   I believe the treatments are inappropriate or unnecessary:        (requires the patiento explain and recommends the patient        consult with his/her physician)    -   I have recovered from my illness    -   I have chosen not to follow the recommended treatments because:        (requires the patient to explain and recommends the patient        consult with his/her physician)

The healthcare delivery methods of the current invention will bedescribed with reference to FIGS. 1, 2 and 3. To aid in identificationof the various steps of the current invention, identifying numbers areprovided for selected portions of the process. Electroniccommunications, such as but not limited to Internet, e-mail, provide themost efficient means for practicing the methods of the currentinvention. However, the methods of the current invention may be readilyadapted to a telephone or telephonic service, standardize electronicdata interchange, text messaging; traditional mail, faxes and other hardcopy communications or a blend of electronic communication andtraditional hard copy communications.

FIGS. 1 and 2 provide flow charts of the method for providinghealthcare. FIG. 3 provides an illustrated description of the preferredembodiment of the current invention. FIG. 1 outlines an embodiment ofthe current invention as it relates to the medical practitioner'sportion of EBM and Ix. FIG. 2 outlines the patient's portion of anembodiment of the current invention. While shown in step wise format,those skilled in the art will recognize that various portions of theprocess can be moved earlier and later in the charts. The methods of thecurrent invention are designed to provide flexibility and adaptabilitydepending on the desires of the local health plan. The format of thecurrent invention may be adapted by any form of health plan. As usedherein, the term “health plan” refers to the organization underwritingthe cost of the healthcare insurance coverage and managing thehealthcare delivery system, and may include self-insured employers,health insurance companies (and their customers to include employers andindividuals who purchase health insurance coverage managed care plans,healthcare CO-OPs, U.S. governmental programs such as Medicare,Medicaid, Veterans Administration, military, state and Federalemployees, and Indian Health Service, and all types of national healthservices and systems in other countries.

As shown in FIG. 1, the method of the current invention begins witheducating the patient and the medical practitioner on the benefits ofthe current invention (referred to herein as “the Program”), to includewhy and how the methods of the Program work. Medical practitioners aremade aware of the Program by a variety of means to include organizedmeetings, targeted mailings and telephone contact, or with the aid of alocal medical provider organizations (medical provider organizationlicensee) contacted to sponsor the Program in a marka, or patients whoinform or ask their medical practitioner to participate. Medicalpractitioners are directed to the Program's Website to enroll online.Prior to receiving treatment, the patient can identify a medicalpractitioner that participates in the Program, but receiving medicalservice from an enrolled and participating medical practitioner is not arequirement in order for the Program to work. Typically, the Programwill be administered by an independent intermediary that operates theWebsite and administers the Program's computer that hosts the Websiteand manages the Program's databases and electronic interfaces with thehealth plan and suppliers of content and services used to operate theProgram. The intermediary sells Program access and service agreements tohealth plan sponsors. Health plan sponsors “bolt-on” the Program totheir actual health plans, which in the case of self-insured employersmay be managed by an independent third party administrator (TPA) or anadministrative services only (ASO) provider. (Though it is notrecommended, in another embodiment of the current invention, the healthplan can also function as the intermediary) It is the intermediary thatwill typically license medical provider organizations (such as a medicalgroup practice, independent practice association or IPA, or aphysician-hospital organization or PHO) to administer provider relationsand promote the Program in a market. An example of these relationshipsis as follows; the independent intermediary setts a user license andservice agreement to the health plan. The health plan may comprise aself-insured employer. The health plan's beneficiaries to include aself-insured employer's covered employees and dependents, collectively,represent the health plan's members. The health plan supplies, typicallyelectronically, a list of eligible members to the intermediary. Theintermediary stores the eligible members listing (file) in the Program'sdatabase. This file of eligible members is updated, typicallyelectronic, by the health plan periodically.

When a member seeks healthcare, they are described as patients. Apatient seeking medical services presents themselves to a medicalpractitioner as a member of the health plan covered by the Program.Subsequently, the medical practitioner provides healthcare services tothe patient. The medical practitioner can voluntarily elect toparticipate in the Program with each service encounter with a coveredpatient. Preferably, the medical practitioner elects to participate byaccessing the Program's Website at the time of service (enrolls in theProgram if he/she has not done so previously) and enters pertinentpatient information and diagnosis(es) information preferably as astandardized diagnosis(es) code(s). (This preferred time of servicemethod of practicing the Program is referred to as thepoint-of-service-initiated or “POSI” real-time version as opposed to theclaim initiated or “CI” after-the-fact version, which is describedlater,) As shown in FIG. 3, the Program's software application comparesthe patient and diagnosis(es) information to the Program's databasestored on the intermediary's computer. If the Program's software finds apatient information match in the Program's database and there isavailable EBM or recommended treatment guidelines (a medicalpractitioner performance standard) and patient educational content(material) and/or patient performance standard related to thediagnosis(es) in the database, then the Program displays the treatmentguideline and educational content (and any other performance standards)to the medical practitioner on the Website Refer to FIG. 3, Step #6).The Website is interactive. As such, if an EBM or recommended treatmentguideline is available, the medical practitioner considers the guidelineand indicates/declares/demonstrates adherence or reason fornon-adherence to the guideline on the Website. In the process, themedical practitioner agrees to allow patient to or acknowledges that thepatient will confirm/rate/concur the medical practitioner'sdeclaration/demonstration of adherence or reason for non-adherence tothe guideline. If educational content and a patient performance standardare available, the medical practitioner selects or searches for thepreferred content (and/or other patient performance standard) and ordersan Ix prescription (and/or other patient performance standard) for thepatient on the Website. Optionally, the medical practitioner is asked torate the patient's compliance to EBM or appropriate care for eachpresenting diagnosis. Again, the medical practitioner may be asked toconsider or initiate other types of performances standards such apre-authorization certification for certain heavy cost medical service,or a pharmacy benefits management service to include electronicprescriptions and lower cost therapeutic substitutions, or the updatingof the patient's web-based personal health record, etc. The patient anddiagnosis(es) information, the medical practitioner's response(s) toguideline adherence, the agree to allow the patient to confirm themedical practitioner's adherence (or non-adherence), the Ix prescriptionorder, the medical practitioner's rating of the patient's compliance,and responses to other performance standards are stored in the Program'sdatabase for subsequent processing to determine the medicalpractitioner's rate of compensation by the intermediary.

The Ix prescription or other performance standard order can be printedby the medical practitioner at the time of service so it can be handedto the patient, or these documents can he mailed or e-mailed to thepatient. Alternating, the medical practitioner may choose to postponeparticipating in the Program until after an insurance claim forreimbursement of the medical services is submitted to the health plan(see description of the CI after-the-fact version below). Therefore theProgram's processes can be initiated at the time of service by themedical practitioner accessing the Program's Website or it can beinitiated by filing an insurance claim for normal medical servicesreimbursement.

Following treatment of the patient, the medical practitioner files aninsurance claim for medical services reimbursement with the health planadministrator. Preferably, the medical practitioner files the claimelectronically (FIG. 1, Step #1). The medical claim contains informationcommonly found on current claim forms such as the patient's name, themedical practitioner's name, a primary medical diagnosis, secondarydiagnoses) and the service provided by the medical practitioner.Preferably, the medical diagnosis and the medical services areidentified by a usual and customary diagnosis and medical servicescodes, and the diagnosis(es) is appropriately linked to thecorresponding medical service(s). The health plan simultaneouslyprocesses the claim (as usual) and also forwards a copy of the claim tothe intermediary (refer to FIG. 1, FIG. 2, Step #1, and FIG. 3, Step#10).

Upon receipt of the claim, the patient and diagnoses information arecompared by the intermediary to any matching information in theProgram's database. Matches then determine if the claim lists eligiblemedical services (referred to as “applicable medical service(s)”)contained in the Program's database. If the claim contains applicablemedical services (FIG. 1, Step #1), then the medical practitioner'sstored responses to the Website queries concerning guideline adherence,(or reason for non-adherence), Ix and other patient performancestandards prescriptions, agreement to allow patient to or acknowledgepatient will confirm/rate medical practitioner's adherence (or reasonfor non-adherence), and medical practitioner's confirmation of thepatient compliance for the diagnosis(es) and other performance standardslinked to the applicable medical services are taken into considerationin determining, the medical practitioner's rate of reimbursement(compensation) as described herein.

If the diagnosis code does not match an accepted guideline in theIntermediary's database FIG. 1, Step #9), the intermediary's computerselects information therapy content that matches the diagnosis code andsends a notice to the service provider. The service provider responds tothe notice by accessing the Program's Website. The service provideraccepts the information therapy provided by the program or researchesand selects information therapy on the website to be prescribed anddispensed to the patient through the program. Depending on thecompensation requirements of the health plan and intermediary, theservice provider may be required to acknowledge or confirm a patientindication of adherence, and then the Program either assigns anintermediate compensation rate or an Ix prescription letter is sent bythe intermediary to the patient (FIG. 2, Step #14),

Medical practitioners must submit an insurance claim for medical servicereimbursement within a time limit or they will not be eligible for thehigher rates of reimbursement or any compensation associated with theProgram for that patient encounter. (As indicated in FIG. 1A, Step #8,missing the time limit for filing a claim would not necessarily affectfuture opportunities to practice the Program.) If information suppliedby the medical practitioner at time of service is not matched to a claimwithin a certain period of time, then the Program may send anotification/warning to the medical practitioner that the claim filingtime limit about to expire.

Alternatively, if the medical practitioner did not access the Website orrespond to the Website queries at the time of service (the POSIreal-time version), then once the claim for medical services areforwarded to the Program's (intermediary's) computer system, the systemwill not identify matching patient and diagnosis information (refer toFIG. 1 and FIG. 1A). If this is the case, then the computer compares theclaim information to the Program's database for applicable diagnoses. Ifthe claim contains an applicable diagnosis, then the computer determinesif the diagnosis is linked to an applicable medical service. If this isthe case, then the computer automatically sends a notification(preferably email and/or fax) to the medical practitioner informinghim/her that there is a Program “opportunity” (“AOI opportunity”)available (3). (This after-the-fact method defines the claim initiatedor CI version of the Program and diagrammed in FIG. 1 and FIG. 1A.)

The notification sent to the medical practitioner advises the medicalpractitioner to access the medical practitioner's portion of theProgram's Website containing EBM guidelines or other healthcare qualityimprovement, patient education material, and other cost control methods(collectively referred to as performance standards). The Program Websiteis preferably a secure website requiring input of the medicalpractitioner's password to gain access to the data contained therein.Alternatively, these access codes may be transmitted by a separate emailor otherwise provided to the medical practitioner. (The method forgaining access to the Website is not critical to the current invention.)

For the purposes of this disclosure the term website refers to theProgram's Websites. The Program's Websites may or may not be located ona central server at the intermediary. Further, the patient and medicalpractitioner portions of the Program's Websites are not necessarilycontained on the same computer system, but may be maintained by healthplan's computers or multiple independent intermediaries. As used herein,the medical practitioner portion of the Program's Website willpreferably be utilized by all parties authorized to access the medicalpractitioner's portion of the Website, including but not limited tonurses, nurse practitioners, physician assistants and other careproviders,

Upon entry of the appropriate codes or passwords at the Website (FIG. 1,Steps #2 and #4 and FIG. 3, Step #5 and #6), the Website identifies thenames of patients, the dates and types of services provided, the medicaldiagnoses and related medical services for the accessing medicalpractitioner or authorized assistant (delegates can be set-up in theProgram's computer, provided the delegate is approved and supervised bya licensed medical practitioner). The

Website also provides the available EBM guidelines or other healthcarequality improvement and cost control methods (performance standards)corresponding to each diagnosis. Preferably, the medical practitionerreviews and confirms the appropriateness of the information found on theWebsite (FIG. 1, Step #5).

The Programs Website is interactive. As such, it queries the medicalpractitioner concerning adherence or reason for non-adherence to EBMguidelines or other healthcare quality improvement and cost controlmethods (performance standards) for the diagnoses (FIG. 1, Step #6 andFIG. 3, Step #7), the agreement to allow the patient to oracknowledgment that the patient will confirm/rate the medicalpractitioner's adherence or reason for non-adherence to the performancestandards, the prescription educational material as Ix to the patient,and patient compliance with the prescribed treatment and guidelines onliving a healthy lifestyle and methods for controlling/managing thepatient's medical condition (FIG. 1A, Step#12 and FIG. 3, Step #9). Themedical practitioner's response to the queries will determine thereimbursement rate used to compensate the medical practitioner forservices rendered on each claim associated with a Program opportunity.If the medical practitioner responds to the queries concerning patientcompliance, prescription of Ix to the patient, declaration/demonstrationof adherence or reason of non-adherence to EBM guidelines or otherhealthcare quality improvement and cost control methods (performancestandards), and the agreement to allow the patient to or acknowledgethat the patient will confirm/rate the medical practitioner's adherenceor reason for non-adherence to the performance standards are appropriate(FIG. 1A, Step #13 and FIG. 3, Step #12), then the Website automaticallydirect compensation to be made according to a higher payment(practitioner reimbursement) rate/scale (FIG. 1A, Step #13). Preferably,the highest rate of medical practitioner compensationment) is selectedwhen the medical practitioner practices the method on a real-time basisusing the POSI version of the Program. (Timelines can be important indelivering information therapy and other services initiated through theProgram to the patient. Therefore, the highest rate of medicalpractitioner compensation is typically assigned when the POSI version ofthe Program is practiced.) Alternatively, the highest rate ofcompensation can be assigned in instances where the medical practitionerhas indicated adherence or reason for non-adherence to a recommendedtreatment guideline, agreed to allow the patient to or acknowledged thatthe patient will confirm/rate the medical practitioner's adherence orreason for non-adherence to the performance standards, prescribed Ix forthe patient (FIG. 1A, Steps #10 and #11) and has rated patientcompliance (FIG. 1A, Step #12 and FIG. 3, Step #9). (It should be notedthat additional medical practitioner compensation can be earned throughthe Program as other performance standards are added to achieve theintended objectives.) Typically, a secondary level or lower rate ofcompensation (payment) is assigned. (selected) when the medicalpractitioner practices the after-the-fact CI version of the Program.Alternatively, the secondary level of compensation can be assigned(selected) when the medical practitioner has prescribed Ix for thepatient and has rated patient compliance, but no treatment guideline isavailable or some other diminished level of service is provided.

As noted above, the Website also queries the medical practitionerconcerning the patient's compliance with health recommendations and EBMguidelines, Ix and any lifestyle activities necessary to improve thepatient's wellness. Preferably, the Website will provide the medicalpractitioner with the opportunity to rate patient compliance with therecommended treatment and behaviors using the following terms:Compliant, Mostly Compliant, Somewhat Compliant, Mostly Non-compliant,Non-compliant and Non-applicable. Alternatively, the patient compliancerating terms may be: Compliant and No Response. No Response may meanpartially compliant, noncompliant, or non-applicable. To receive thehighest compensation level for the services provided, the medicalpractitioner may need to respond to the request for a patient compliancerating. The ratings provided by the medical practitioner will be storedby the Program awaiting a response by the patient to the prescribed Ix.However, the patient will not have the ability to see the medicalpractitioner's rating unless the medical practitioner has selected theoption to permit the patient to view the rating.

Typically, the medical practitioner must access the interactive Websitewithin 48 to 96 hours of receipt of the after-the-fact, CI notificationin order to qualify for the higher payment rate scale. In the preferredembodiment, the medical practitioner is required to respond to thenotice within 48 to 96 hours or two to four business days. If themedical practitioner does not respond within the indicated period oftime (FIG. 1A, Step #8), then the Website will direct compensation to bemade according to a lower (or lowest) rate scale or to cause the Programopportunity for the medical practitioner to expire resulting in nocompensation to the medical practitioner association with the Programfor that opportunity (FIG. 1A, Step #8 c).

As previously indicated, the Program's Website is interactive. Toprovide the maximum flexibility and greatest possibility of improvedclinical outcome for the patient, the method of the current inventiondoes not rigidly limit the medical practitioner only to the EBMguidelines in order to receive the highest degree of compensation.Rather, the Program's Website provides the medical practitioner with theoption of indicating the treatment falls outside of the guidelines whileexplaining the reason for prescribing treatment outside of theguidelines. Provided that the medical practitioner completes the sectiondescribing an appropriate reason for non-adherence to the recommendedtreatment (FIG. 1, Step 18 a), the Program's Website will still selectthe highest compensation level for the medical practitioner. Thus, thepresent invention avoids the practice of “cookbook medicine” byencouraging the medical practitioner to use appropriate clinicaljudgment and medical skills when deciding to on whether or not to followthe EBM guidelines. In order for this “anti-cookbook” feature to work,the medical practitioner must agree to allow the patient toconfirat/rate/concur with the medical practitioner'sdeclaration/demonstration of adherence or reason for non-adherence tothe recommended (EBM) care.

As previously indicated, in the preferred method the medicalpractitioner must prescribe educational material as Ix for the patientand (alternatively) rate patient compliance with directions/guidelineson living a healthy lifestyle and other methods for controlling/managingthe medical condition before becoming eligible to receive payment at thehighest or second highest (intermediate) compensation rates.

Again, the medical practitioner is not required to indicate compliancewith the EBM guidelines; however, failure to respond within 48 to 96hours or indicating non-adherence without providing an appropriatereason for treatment outside of the EBM guidelines can have a negativefinancial impact on the medical practitioner. Specifically, theseactions will trigger the intermediary's computer system to select thelowest possible payment scale for the medical practitioner's services(FIG. 1A, Step #8 c) or terminate that “opportunity” for the medicalpractitioner to earn any additional compensation at all. If the medicalpractitioner fails to prescribe educational material as Ix for thepatient, then the Website will direct the selection of the lowestpayment scale for compensation of the medical practitioner or notcompensation the medical practitioner for that “opportunity” at all.Furthermore, if the medical practitioner fails to participate in theProgram for any given “opportunity” or to satisfactorily complete thesteps that are required of a successful participation for any given“opportunity” as established by the health plan sponsor (in consultationwith the intermediary) and adjudicated by the intermediary within thespecified time limit, then the medical practitioner's opportunity willexpire and he/she will not be compensated,

As a result of the medical practitioner's failure to successfullyparticipate in the Program for any given “opportunity,” the patient's“opportunity” to participate may or may not be affected in accordancewith Program requirements established by the health plan sponsor inconsultation with the intermediary. Typically, the patient's“opportunity” to participate is not affected. In this case, thediagnosis listed on the medical service claim for payment submitted bythe medical practitioner provides the means by which the intermediary'scomputer system can automatically generate an Ix prescription letter,email or other type of notification to the patient that informs thepatient of chance to participate in the Program for said “opportunity.”This notification to the patient may inform the patient that the medicalpractitioner failed to participate in the Program for said “opportunity”or, if it is the case, a series of ‘opportunities,” As a result, thecurrent invention can promote consumerism by providing patients withimportant medical service quality information to help them be morediscerning in their healthcare choices or to encourage them to urgetheir medical practitioners to participate in the Program. This methodalso heightens the current invention's “checks and balances”(“doctor-patient mutual accountability”) designed to motivate betterhealth behaviors and healthcare,

Thus, the method of the current system provides a financial incentive tothe medical practitioner to follow the EBM guidelines or to provide anappropriate reason for deviating from these guidelines, provided themedical practitioner agrees to allow the patient to confirm/rate/concurwith the medical practitioner's declaration/demonstration of adherenceor reason for non-adherence to the guidelines. Additionally, the methodof the current invention provides a financial incentive to the medicalpractitioner to prescribe Ix to the patient and to rate patientcompliance with the prescribed treatment/lifestyle necessary to managethe medical condition. Furthermore, the method of the current inventionprovides a financial incentive to the medical practitioner to practicethe Program on a real-time basis as opposed to after-the-fact. However,the method uses financial incentives to create other perhaps strongerincentives for the medical practitioner to practice the method. Theseincentives include the medical practitioner's desire to: 1) improvecommunications with patients; 2) improve the patients' understand oftheir medical condition and how to self-manage their health; 3) providea means to help/motivate patients be more compliant to recommended careand adopt and maintain better health habits; 4) increase productivity;5) gain a degree of medical malpractice risk management; 6) have accessto the latest and best methods for treating diseases and injuries; 7)incorporate other beneficial performance standards; and last but notleast 8) prevent patients and others from thinking he/she practicesinferior healthcare or, worse yet, learn that tie/she is not truthfulabout what kind of medicine he/she practices. This final (8^(th))incentive (i,e., motivator) describes one of the checks and balancesthat is unique to the current invention. In effect, the medicalpractitioner is aware that the patient earns a financial reward forbecoming qualified to rate the practitioners adherence to andperformance against high and beneficial standards. The medicalpractitioner is also aware that patients' ratings will be aggregated andcompared to the medical practitioner's peers. This is a powerfulincentive that encourages medical practitioners to participate in theProgram and to practice medicine that is recommended by the medicalprofession or to provide appropriate reasons for non-adherence. Ingeneral, treatment according to the EBM guidelines and appropriatetreatment outside of the guidelines coupled with patient compliance withtreatment protocols and a healthy lifestyle will produce better clinicaloutcomes. Further, the prescription of educational material as Ix to thepatient empowers the patient to be more compliant with their medicalpractitioners treatment orders and instructions, leading to improvedclinical outcomes. Additionally, the patients access to educationalmaterial and the process of assessing the patient's understanding ofthat material provides the patient with the empowerment and additionalmotivation to improve the medical practitioner's medical condition,which leads to improved medication adherence and other therapies, whichleads to a decrease in expensive services such as hospitalizations.Thus, the current invention provides a method for improving clinicaloutcomes, promoting healthiness, which leads to reduction in healthcarecosts. Clearly, the current invention integrates the activities of thepatient and medical practitioner by encouraging the incorporation ofEBM, Ix and other beneficial performance standards by combiningfinancial incentives with powerful psychosocial motivators.

In order to achieve medical practitioner participation and adherencewhile preventing fraud and abuse, the Program's Website softwareapplications provide the means to monitor and audit the medicalpractitioner. In one aspect, the Website provides the means for trackingthe medical practitioner's access to the Website. This trackingmechanism provides an indication of the medical practitioners use of theEBM guidelines. For example, the Program's Website tracks the accesstime for each webpage reviewed, if the time of usage for each page doesnot meet a predetermined minimum, then the medical practitioner may bequestioned concerning the legitimate usage of the EBM guidelines.However, the predetermined minimum time period for accessing a webpageis not a rigid requirement Rather, the minimum access time period mayvary from practitioner to practitioner and from diagnosis to diagnosisbased on various parameters such as but not limited to the medicalpractitioner's area of expertise and experience and whether a particularwebpage has been previously reviewed and/or printed by the medicalpractitioner. If a new medical treat e t is established as recommendedby the medical community and is new in a EBM treatment guideline, thenthe invention's Website application may prevent the medical practitionerfrom exiting that webpage or from receiving a higher rate ofreimbursement or additional compensation until the medical practitioner“drilis-down” into the application to learn about this new medicaldevelopment, advancement, and/or treatment. The Program can alsoadminister exams to verify medical practitioner compliance and toprevent fraud and abuse. However, the strongest means to prevent fraudand abuse rests with the Program's “doctor-patient mutualaccountability” feature. Patients are educated by an independent expertsource about how their medical practitioner should care for theirmedical condition, and then patients are immediately queried about howtheir medical practitioner is performing against what they have learned,and how consistent the medical practitioner's declaration of adherenceis to, again, what they have learned. This represents a fair andappropriate way to rate medical practitioner performance (especiallycompared to web-based. satisfaction surveys) that balances the interestsof the medical practitioner with the interests of the patient and thehealth plan sponsor.

In another aspect, the Website provides the means for monitoring thefrequency of treatments outside of the EBM guidelines (FIG. 1A, Steps #8and #8 a). Thus, the current invention provides health plans using themethods of the current invention with the ability to audit medicalpractitioners who may not be using the best treatments for theirpatients by using treatments outside of generally accepted procedures.As indicated above, the methods of the current invention are flexibleand can be adjusted for individual practitioners on the basis of theirpractice area and experience and also adjusted to incorporate additionaltypes of performance standards linked to specific incentives (as long asone or more incentive is interactive involving the checks and balancesbetween the medical practitioner and the patient facilitated by thecurrent invention) to achieve the objectives of better health and betterand more affordable healthcare. The current invention's capability toadjust and expand performance standards and incentives to achievespecific objectives is referred to as “precision-guided incentives andperformance standards.”

The foregoing steps of the method of the current invention provide anincentive to the medical practitioner to comply with the treatmentsspecified in the EBM guideline database and to rate patient compliancewith prescribed reatment/satifestyle necessary to manage the medicalcondition. The current invention is design to accommodate EBM guidelinesfrom any unbiased, independently derived, highly reputable source thathas used generally accepted testing protocols to establish recognizedlevel of proof. Therefore, the Program does not endorse any one sourceof guidelines, content or medical intervention. However, the Program isconstantly seeking the best possible guidelines, content and medicalinterventions to integrate with the current invention.

Providing an incentive to the medical practitioner addresses only onepart of the total cost of healthcare. In order to further improve thepatient's clinical outcome, promote healthiness, and enhance healthcarecost control, the patient must also play a role. Accordingly, themethods of the current invention provide an incentive to the patient totake a pro-active approach to recover from and prevent adverse medicalconditions.

With reference to FIG. 2, the method of the current invention providesthe medical practitioner with the option of prescribing Ix and otherperformance standards to the patient (F 1A, Step #11). In the preferredembodiment, the method encourages the medical practitioner to prescribeIx and other performance standards to the patient by rewarding themedical practitioner with additional compensation. Preferably, themedical practitioner wilt prescribe the Ix and other performancestandards at the same time the medical practitioner is responding to theWebsite's inquiry regarding medical practitioner's compliance with EBMguidelines for the prescribed medical treatment. The prescribed Ix willnormally be provided via an Internet website or a telephone/telephonicservice. For the remainder of this discussion, the source for theprescribed Ix and other performance standards wilt be referred to as theProgram's Website; however, other sources of information are within thescope of the present invention.

If the medical practitioner prescribes Ix for the patient, then a noticein the form of an e-mail, fax, text message, letter or other similarcommunication will be sent automatically to the patient by the Programor handed to the patient at the time of service by the medicalpractitioner (or the practitioner's staff). This patient notification(FIG. 2, step #14) may contain the medical information or morepreferably the notice will contain the information about the benefits ofthe Program, including the financial incentives available to thepatient, and instructions on how to gain access to the Program'sWebsite. The notification will also inform the patient that his/herparticipation in the Program is completely voluntary.

As mentioned previously, if the medical practitioner fails toparticipate or fails to successfully complete an “opportunity,” then thediagnosis listed on the medical service claim for payment submitted bythe medical practitioner provides the means by which the intermediary'scomputer system can automatically generate the notification to thepatient (FIG. 1A, Step #8 c) that informs the patient of his/her chanceto participate in the Program for said “opportunity.”

Upon receipt of the correspondence/notification, the patient will bedirected to the patient portion (section) of the Program's Website. Onceonline, the Website will inform the patient (FIG. 2, Step #15) thathe/she can earn a financial incentive and gain valuable healthinformation by successfully completing the following tasks: 1) read theeducational material presented to them on the Website about his/herhealth condition, recommended (EBM) care, other pertinent and beneficialperformance standards (FIG. 2, Step #15); 2) answer questions presentedon the Website to demonstrate his/her understanding of this material(health literacy assessment) (FIG. 2, Steps #17, #17 a, and #17 b); 3)declare his/her adherence or reason for non-adherence to the recommended(EBM) and appropriate care or other beneficial performance standards(FIG. 2, Steps #18, #18 a, and #18 b); 4) report (or have healthmonitoring devices report) his/her health status such as weight, bloodpressure, blood sugar, and resting heart rate (FIG. 2, Step #17 c); 5)authorize to access pharmacy records to verify that prescriptions havebeen filled, and/or request verification that the patient hassuccessfully participated in a health assessment and/or screeningprogram, and/or release information that he/she is participating in areadiness to change program, and/or authorize access to lab and othertest results, and/or request verification that the patient has seen oris scheduled to see a medical specialist or has successfully completedor scheduled to complete other recommended therapies, and/or releaseinformation concerning his/her participation in therapeutic socialnetworking, and/or authorize or affect the population of a personalhealth record with pertinent information and request his/her medicalproviders to use the personal health record in his/her treatment toachieve coordination of care and to prevent duplication of care, and/orparticipate in a pre-authorization certification of expensive tests andservices (such as surgeries and hospitalizations) through the Website toprevent unnecessary procedures and insure better clinical outcomes,and/or release an advance directive, and/or demonstrate his/her healthybehavior by any other means; 6) after acknowledging their medicalpractitioner's responses to the Website question(s) about adherence orreason for non-adherence to a recommended (EBM) treatment or otherperformance standards (and taking into consideration the informationhe/she have just read on the method's Website), confirm/rate/concur withhis/her medical practitioner's declaration/demonstration of adherence orreason for non-adherence to the performance standard (FIG. 2, Step #19);and 7) agree to allow his/her medical practitioner to have access tohis/her health literacy assessment and declaration/demonstration ofadherence or reason for non-adherence to the prescribed treatments andIx (or other performance standards) (FIG. 2A, Steps #19 a, #20 a, and#20 b). (This agreement by the patient reinforces the Program'sstrategic checks and balances (“doctor-patient mutual accountability”)by making the patient aware that someone he/she respects and trusts whenit comes to his/her health, namely his/her medical practitioner, hasaccess to (and may rate the patient on) their health literacy assessmentand declaration/demonstration of adherence or reason for non-adherenceto Ix and other performance standards creates powerful motivation forthe patient to improve and maintain good health behaviors. The Programis also able to compare the patient's declaration/demonstration ofcompliance responses against his/her medical practitioner's rating ofhis/her health compliance. If the compliance indicators between thepatient and the medical practitioner match, then the Program wouldindicate that the patient is be eligible for an additional financialreward from his/her health plan.)

With reference to FIG. 2, the patient is expected to review the healtheducational material made available by the Program's Website (FIG. 2,Step #15). The review of the prescribed educational material as Ix issupplemented with a questionnaire to be completed by the patient toassess the patient's understanding of and adherence to the material. Inthe preferred embodiment, the Program's Website also provides the meansto monitor the patient's access of the Website and completion of thequestionnaire (FIG. 2, Step #16). This monitoring aspect provides thenetwork with the means to audit patient compliance with the Ix and othertreatment prescribed by his/her medical practitioner. Further, themonitoring system provides the ability to award “points” to the patientfor reading the Ix, and for answering the questionnaires that indicatethe patient's knowledge and adherence to recommended treatments. As ameans to insure compliance and prevent fraud and abuse, the network candesignate a minimum period of access time necessary prior to awarding apoint for reviewing that section of the Ix. By requiring a minimum timeperiod, the method of the current invention ensures that the patientperforms more than a cursory review of the information provided.

Following completion of the questionnaires that tests the patientsknowledge and adherence to recommended (EBM) care, establishes thepatient's agreement to allow his/her medical practitioner to have accessto and rate his/her responses and adherence, and rates his/her medicalpractitioner performance against recommended (EBM) care; the Websitescores the patient's answers and awards points to the patient's accountaccording to the patient's responses. Following scoring, the patient hasthe option of further reviewing the Ix and repeating the questions oranswering additional questions. Thus, the current invention provides thepatient with the ability to gain further knowledge of his/her conditionwhile enhancing the number of points awarded to his/her account.Clearly, the comprehensive nature and flexibility of the Program'sWebsite provides the patient with the tools necessary to improve his/herhealth literacy, emprovement, motivation, and the clinical outcome ofhis/her treatment and to improve his/her overall general health.Optionally, the health plan may elect to award patients with additionalpoints and financial rewards for reviewing other medical information andaccomplishing other performance standards intended to improve health andcontrol cost, that are made available through the Program.

Upon completion of the Ix and indication of adherence and understandingof recommended and appropriate care, agreement to allow his/her medicalpractitioner to have access to and/or rate/acknowledge/confirm his/herresponses to the Website questionnaires, and the rating of his/hermedical practitioners performance; the patient is provided with a meansfor notifying the health plan of the receipt and review of the Ixmaterial. Additionally, the patient will be provided with the option ofsharing the medical practitioner's rating of patient compliance with thehealth plan. Typically, the patient will be provided with separateoption boxes or other “clickable” devices on the Website to indicate thepatient's desire to share the medical practitioner's compliance ratingand to transmit a notice of completion of the Ix material to the healthplan and/or employer. In the preferred embodiment of the currentinvention, the Program Website transmits the patient's actual responsesto the questionnaire to the medical practitioner or posts the responseson the Website for access by the medical practitioner. Though thesechoices are optional to the patient, if the patient elects not to shareinformation, then the health plan will most likely not provide thefinancial reward(s) to the patient.

In view of the incentives offered by the method of the currentinvention, the patient will likely request transmission of such noticesto the health plan and/or employer. Upon receipt of such notices, thehealth plan has the option of providing a financial reward to thepatient based on the patient's completion of the Ix,declaration/demonstration of adherence or reason for non-adherence tothe recommended care, rating of his/her medical practitioner, and thepatient's compliance and performance rating of the medical practitioner.In keeping with the flexible nature of the current invention, thefinancial reward may be granted upon the complaion of each prescribedIx, indication of adherence, agreement to allow the medical practitionerto have access to (and rate) the patient responses to the website'squestionnaires, and the patient's medical practitioner rating portion.Before the intermediary assigns a reward to the patient, the patientdeclares or demonstrates adherence to the performance standard. Theparty paying the reward may establish point thresholds for payouts. Inthe case of point thresholds, the patient's points are accumulated andupon reaching a predetermined level, the financial reward can be paid tothe patient.

It should be noted that as with the medical practitioner, the patient'sparticipation in the Program for a given “opportunity” is voluntary andmay or may not affect the medical practitioner's compensation forparticipating in the Program for said “opportunity.” In a preferredembodiment of the current invention, the medical practitioner'scompensation is not affected by the patient's non-participation.

Typically, a patient will not to earn a financial reward through theProgram if the Patient: fails to complete Ix “opportunity” within theestablished time limit; or fails to pass a health literacy test ordemonstrate knowledge of the Ix educational material (though literacytests in the Program are open book, meaning that patients are asked toread the educational material again when they miss a health literacyquestion); or fails to report health status; or denies MedicalPractitioner access to his or her Website questionnaire responses; orfails score enough points answering Website questionnaires (FIG. 2A,Step #22).

As noted above, the method of the current invention preferably includesthe medical practitioner's confirmation of the patient's health literacyand the patient's indication of adherence to recommended treatments. Theprocess of the patient sharing information with his/her medicalpractitioner and health plan and/or intermediary creates another checkand balance that is designed to help improve health behaviors andcontrol costs. In effect, the patient is aware that his/her answers toquestions on the Website (or over the telephone) about his/hercompliance to performance standards will be available to his/her medicalpractitioner, health plan, and intermediary for review andauthentication. The patient's desire to demonstrate his/her knowledgeand compliance to his/her medical practitioner is a strong motivator.The psychological consequence of being found untruthful by someone thatthe patient trusts and respects, namely the medical practitioner, is apowerful motivator for the vast majority of people.

Obviously, the ideal embodiment of the current invention involvesparticipation of both the medical provider and the patient with each andevery “opportunity.” However, one important aspect of the currentinvention that is unique has to do with its functionality andeffectiveness when only one of the two parties participates. Sinceneither the medical practitioner nor the patient knows if the otherparty will or will not participate in the confirmation of the other'sperformance, then the psychology that inspires best behaviors inherentto the doctor-patient relationship is present for either party even whenthe other party does not participate. In the case of the medicalpractitioner, he/she does not want his/her patients to think or learnthat he/she practices inferior medicine after his/her patients completethe Program's information therapy process. However, the medicalpractitioner will have no way of knowing whether any given patient willparticipate in any given “opportunity.” So to be safe, the medicalpractitioner is inspired to incorporate EBM (best practices) with everyencounter involving a patient covered by the Program just in case. Infact, the Website reminds the medical practitioner of this fact eachtime he/she is asked to respond to the acknowledgment that the patientwill (may) rate the medical practitioner's performance against anindependently derived EBM standard. Conversely, the patient does notwant his/her trusted and respected medical practitioner to think he/sheis health illiterate and/or non-compliant to recommended treatments andhealthy behaviors. Again, he/she will have no way of knowing if his/hermedical practitioner will or will not review his/her information therapyand declaration or demonstration of adherence responses to the Websitequestionnaires. Therefore, each time a patient participates in theProgram and accepts the Website agreement to allow his/her medicalpractitioner to have access to his/her Website responses, the Program'spsychological motivators are helping to inspire the patient to behealthy and compliant. This is why the medical practitioner'sacknowledgment of the patient rating/confirmation and the patient'sagreement to allow the medical practitioner to access/rate/confirm“switches” incorporated into the website are such an important featureof the current invention.

Finally, the current invention also preferably provides for patientinquiries of the medical practitioner through the Website, by email orother similar means, during Ix sessions. Thus, the current inventionintegrates the patient's Ix with the medical practitioner's medicaltreatment and provides financial rewards to the patient based oncompleting the educational aspects of Ix as well as financial rewardsfor adopting a healthy lifestyle and adherence to treatment protocols asrecommended by the medical practitioner, for agreeing to allow themedical practitioner to confirm/rate/acknowledge the patient's healthliteracy and indication of adherence to healthy behaviors andrecommended treatments, and for rating their medical practitioner'sperformance against recommended and appropriate care.

In accordance with the Health Insurance Portability and AccountabilityAct (HIPAA), the notice to the health plan and any notices to any otherthird parties will not divulge any protected patient health informationunless arrangements have been made to meet HIPAA requirements,

In the method, the service provider (medicalpractitioner/doctor/physician/clinician) and patient may be required toperform an action or physical act to demonstrate as oppose to declareadherence to a performance standard. An action or physical act may ormay not be captured on the Website. Since the action or physical act maybe captured by the Website, then the service provider and patient wouldbe asked to acknowledge the action or physical act of each other. Thisimplies that the action or physical act can be independently, verifiedby the acknowledging party and authenticated by the intermediary. Anexample of a performance standard involving a verifiable action is theservice provider electronically prescribing drug therapy to the patientthrough the Website. Since this action is captured by the Website, themethod would ask the service provider to agree to have the patientacknowledge his/her action (adherence to a performance standard), andwould preferably involve the patient acknowledging his/her serviceprovider's adherence to the performance standard. Therefore, the terms“declare and confirm” and “declaration and confirmation” are synonymousto “demonstrate and acknowledge” and “demonstration and acknowledgment”when a verifiable action or physical act is involved.

The present invention is designed to allow the health plan and theintermediary to select (or determine a variety or varying amount ofperformance-based incentives depending upon the level or degree ofadherence or performance by the service provider and the patient againsta performance standard or multiple performance standards. An example ofthis feature involves establishing one amount of compensation for theservice provider when he/she prescribes information therapy to thepatient and an additional (or separate) amount of compensation whenhe/she uses a drug therapy management system to electronically prescribepharmacy to the patient. In this case, the intermediary wouldauthenticate the service provider's performance and determine the levelof performance-based incentive to be paid to the service provider.Alternatively, the method may require the patient to confirm andacknowledge the service provider's performance in addition to theintermediary's authentication to determine the level of adherence(performance) and compensation.

Another embodiment of the present invention comprises pre-authorizationcertification programs that integrate the patient into the authorizationprocess. This is referred to as “patient-integrated pre-authorizationcertification” and as “doctor-patient mutual accountabilitypre-certification.” In effect, patient-integrated pre-authorizationcertification involves compensating the service provider for prescribingan educational material as information therapy through the Website tothe patient when expensive or risky medical services (such as surgeriesor hospitalization) are planned. The patient is financially rewarded forreading about his/her conditions, the planned treatment and treatmentalternatives. The patient would then be required to demonstrate his/herknowledge by taking a test so he/she can be qualified to authorize theplanned treatment or consult further with his/her service provider aboutthe treatment and ask about alternative treatments or seek a secondopinion or refuse the treatment.

Another embodiment of the present invention comprises an enhancement tohospital care management systems by integrating patients into thehospital care process. This is referred to as “patient-integratedhospital care management program.” In effect, patients earn financialrewards for performing certain tasks associated with theirhospitalizations. One such task is to designate a personal advocate suchas a family member or friend. This method of the invention compensateshospitals and attending physicians for prescribing a hospital care planand discharge instructions through the Website or during admission andat discharge to the patient and his/her advocate. Pre-admission, duringthe admission and after discharge, the patient and/or advocate would bequeried through the Website to demonstrate their knowledge of thehospital care plan and discharge instructions. The Website then asks thepatient and advocate to rate the hospital's and attending physician'sperformance against the hospital care plan. The patient would be askedto declare his/her compliance to hospital care plan and dischargeinstructions. As a means for the intermediary to authenticateperformance, the hospital and attending physician could also be requiredto access the Website to enter the name of patient's advocate and toindicate the patient's adherence to the hospital care plan,

Clearly, the method of the current invention provides a means to incentand motivate the patient to take an active role in managing theirmedical condition. As a result, the clinical outcome of the patientsmedical treatment will be enhanced. Thus, the methods of the currentinvention enhance the quality of medical care by encouraging the patientand medical practitioner through financial rewards and mutualaccountability checks and balances to adhere to the scientificallyproven best treatment guidelines or preferred methods, healthy behaviorsand other performance standards, and by enabling the patient throughinformation therapy to manage the treatment of the medical condition toachieve a higher level of health. By enhancing the quality of medicalcare and increasing the patients ability to manage their medicalcondition, the current invention promotes better health and healthcare,which reduces the overall cost of healthcare; while providing anincrease in compensation to the medical practitioner, a financial rewardto the patient, and cost savings that produces a return on investment tothe health plan sponsor. Thus the current invention aligns the interestsof these three key stakeholders in a win-win-win arrangement.

Collectively, the descriptions and illustrations presented herein andthe terms such as “checks and balances,” “declare and confirm,”“demonstrate and acknowledge,” “doctor-patient mutual accountability,”“triangulation,” “win-win-win,” “mutual accountability partnership,”“precision-guided incentives and performance standards,” and “alignmentof interest” or “AOI” define the invention's unique “interactive”characteristics between medical providers, patients, and health plansponsors. Hence, the invention can be accurately described as a“web-based interactive provider-patient incentive system.”

FIG. 3 is a diagrammatic illustration of the method of the presentinvention. The embodiment of FIG. 3 comprises an Information Therapy(Ix) Program. The following discussion provides a step-by-stepdescription intended to illustrate the of combining the method andsystem of the current invention with the mechanics of the Ix Programprocess and is not intended to imply that this is the only applicationof the invention. The following discussion is made in reference to FIGS.3-16. FIG. 3 illustrates the steps of the process described below. FIG.4-16 provide exemplary webpage interfaces useful with the presentinvention.

The example of the current invention discussed below comprises aweb-based healthcare delivery incentive method (system or program) that,in this example, is referred to as the Ix Program. The Ix Programdescribed herein involves four parties: health plan sponsor (healthinsurance companies, self-insured employers, and the Medicare andMedicaid programs) that purchase the Program and underwrite (fund) thecost of health care of persons (beneficiaries/plan members) covered byhealth insurance (health plan); medical providers (service providers,physicians/doctors, medical practitioners, healthcare providers, andclinicians) who participate in the Program; beneficiaries(patients/consumers) of a health plan that offers the Program; and anintermediary (Informediary) that operates the Program and administersthe three agreement between the health plan sponsor, the plan member andthe medical provider.

The current invention comprises the following elements: a performancestandard or set of performance standards; an Internet website withsoftware applications (Ix Program Website or Website); a computer systemoperated by the intermediary that hosts the Website and contains certainIx Program databases; financial rewards; and a system of checks andbalances. The performance standards may comprise a set of healthcaretreatment standards that have been shown to be effective at improvinghealthcare rendered by providers, improving the health of beneficiaries,and controlling healthcare costs such as evidence-based medicine (EBM)treatments and information therapy (Ix) prescriptions. The Websitecontains the Ix Programs proprietary applications that effectuate thesystem of checks and balances and performance standards or informationabout performance standards operated by the intermediary. The financialrewards and other types of non-financial incentives are disbursed by thehealth plan sponsor's administrator (TPA, ASO provider, or healthinsurance company) to providers and beneficiaries for successfullypracticing the Ix Program as determined by the intermediary. The systemof checks and balances is established between the medical provider andbeneficiary to motivate Ix Program participation and performancestandard compliance, and to prevent fraud and use.

With reference to FIG. 3, at Step #1 the health plan sponsors adopt theIx Program by purchasing the Ix Program from the intermediary (FIG. 3)as a “bolt-on” benefit to the sponsors' health plans. Typically, paymentfor a “bolt-on” benefit is made on the basis of the number of planmembers (consumers/patients/beneficiaries) who are covered by the IxProgram, often referred to as a per-member-per-month (PMPM) access fee.

At Step #2 the beneficiaries enroll, receive orientation, are informedof their opportunity to earn financial or other types of rewards, andare encouraged to request information therapy from their serviceproviders. Beneficiaries may be introduced to and enrolled in the IxProgram through their employment or health insurer. The intermediary andthe health plan typically orient beneficiaries (patients) to the IxProgram through written materials, instructional videos, and Websitetutorials. One instruction advises beneficiaries to seek care from aparticipating provider (physician) or to encourage their physician toparticipate in the Ix Program. Beneficiaries should expect to receivecare from his/her provider that meets the performance standard such asEBM treatments and information therapy prescriptions. The Ix Programorientation explains that financial rewards are available to thebeneficiary when he/she accesses the Website and appropriately respondson-line (or over the telephone through a telephonic interface to the IxProgram) to information therapy prescribed by his/her physician and/ormeets other performance standards.

At Step #3 the service providers (physicians/clinicians/medicalpractitioners) receive orientation and are encouraged to prescribe Ix.An exemplary webpage illustrating the web interface used in Step #3 isshown in FIG. 4. Physicians may be oriented to the Ix Program by theintermediary and health plan in a variety of ways including organizedmeetings, in-office presentations, mailings, through professionalorganizations, and faxed notices from the intermediary. Another commonmeans of introduction may involve patients requesting or suggesting thattheir physicians participate in the Ix Program. The service provider isinformed that by practicing the Ix Program, he/she: 1) should have moreknowledgeable and compliant patients, 2) will be rendering a higherstandard of care, 3) may gain a degree of malpractice risk management,4) should experience an increase in productivity, 5) should expect abetter clinical outcome, and 6) will be appropriately compensated forhis/her time and effort. The provider is also informed that the patientwill be seeking and expecting information therapy, EBM treatments,and/or other performance standards, and that the patient will be askedto rate the physician's level adherence to the performance standard.Finally, medical providers are informed that participation in the IxProgram: is purely voluntary, even on an encounter-by-encounter basis;involves no costs to set-up or on-going purchases except for Internetaccess; is designed to be fast and easy to use; and is anti-cook,encouraging medical providers to use their clinical judgment in treatingpatients, Physicians enroll in the Program online through the Website.

At Step #4 a beneficiary visits a physician and, if he/she wishes, canask for information therapy and/or other performance standards. When thebeneficiary seeks a medical provider participating in the Ix Program orrequests services that satisfy the Program's performance standard(s)from his/her physician, it represents the first in a series of checksand balances (nonfinancial or psychological incentives/motivators)between the doctor and patient that encourages positive behaviormodification. During an office visit (or other types of medicalencounter), the physician renders treatments to the patient and files anormal insurance claim to the patient's health plan for compensation.The physician would typically collect any co-payments or annualdeductibles from the patient according to the patient's health planbenefits.

Continuing with Step #5, the physician accesses the Ix Program throughthe Website. The physician can practice the Ix Program in many ways. Twoexemplary methods of practicing the current invention are discussedherein. An exemplary webpage illustrating the web interface used in Step#5 is shown in FIGS. 5 and 6.

The physician can initiate the process at the time of service (in thepresence of the patient or shortly thereafter) by accessing the Websiteand using the Point of Service Initiated or POSI real-time version ofthe Ix Program (FIGS. 4, 5, and 6). On the Website, the physician entersthe beneficiary's name or identification number and diagnosis(es) (SeeFIGS. 5, 6 and 7) and responds to questions and/or performs services atStep #7, as described below. The physician's POSI responses are storedin the intermediary's computer system database for later processing. Ifthe physician forgets or fails to use POSI, then the process can beperformed “after-the-fact” using the Claims Initiated or CI version ofthe Ix Program. FIGS. 8a and 8b are exemplary webpages illustrating theweb interface used in Step #5 to evaluate the performance standardprovided by the Program in response to the received diagnosis code.

The Website's proprietary software applications determine whether thePOSI or the CI version is to be used for each occurrence of care. Thisis accomplished when the intermediary receives (preferablyelectronically) a copy from the health plan administrator of thephysician's insurance claim for the services rendered during the patientencounter (as mentioned in Step #4, above, and described in Step #10,below). The Website's software applications look to match the claiminformation to POSI responses by the physician stored in theintermediary's database. If there is a match, then the intermediaryorders compensation for the physician as described in Step #12, below.If there is no match, then the intermediary sends an e-mail notificationto the physician to practice the Ix Program “after-the-face,” This“after-the-fact” process that uses a physician's insurance claim toinitiate an e-mail notification to the physician is, in effect, theClaims Initiated or CI version of the Ix Program. The CI version is notdepicted in the diagram. However, with the exception of how theprocesses are initiated, the POSI and CI versions are similar.

At Step #6 the Website supplies EBM treatment guidelines or other typesof performance standards, provided guidelines and other types ofperformance standards exist for the patient's diagnosis). The Websiteautomatically displays EBM treatment guidelines or other types ofperformance standards to the physician related to the patientsdiagnosis(es) and/or health plan benefits. In the case of the IxProgram, if a guideline does not exist, then the Website displaysmedical educational content related to patients diagnosis(es) (FIGS. 8Aand 8B). Immediately following Step #6 the service provider acknowledgespatient will confirm/rate/concur with/acknowledge service provider'sperformance after the patient completes an Ix prescription.

Other types of performance standards include but are not limited to:web-based patient-integrated pre-authorization certification ofexpensive medical services; web-based patient-integrated hospital caremanagement services; web-based drug therapy and pharmacy benefitmanagement programs including e-prescription, therapeutic drugsubstitution, automated drug interaction warnings, and patient drugeducation with knowledge assessment; the adoption and use of personalhealth records; web-based health risk assessment programs; web-basedreadiness to change programs; web-enabled health screening programs;web-enabled disease management programs; web-based medical educationprograms; web-enabled wellness and fitness programs such as smokingcessation, weight management and health club usage; web-enabled healthmonitoring devices; promotion of web-based patient healthself-management and therapeutic social networking programs; anintegrated advance directive; a medical provider quality and costtransparency program; and or other programs and systems shown ordesigned to improve the standard of care, promote healthiness andcontrol costs or make health care more affordable.

In Step #7, the physician responds to Website questions designed toinitiate an Ix prescription to the patient in the case of the Ix Programmodel of the invention, if a guideline is displayed on the Website (FIG.8A and 8B), he physician is asked to answer two or three questions:

a. “Are you following this guideline for this patient? Yes or No” Inconjunction with this question, the physician may also be asked torespond to one of the following statements: “I understand that mypatient will be asked to confirm or rate my declaration of adherence tothis guideline after my patient has been educated about recommendedtreatments, “Acknowledge,” or “I understand that my patient will beasked to concur with my reason for not adhering to this guideline aftermy patient has been educated about recommended treatments. Acknowledge,”(Note: This understanding or agreement can also be included in theservice provider Website agreement, which is accepted by the serviceprovider at time of enrollment and/or each time the service providerlogs onto the Website.) A physicians answer to this adherence questionand his/her acknowledgment of the patient's confirmation together canhave a profoundly positive effect on how healthcare is delivered as aresult of the current invention. This particular application of the“declare and confirm” method, coupled with patient education, is one ofthe most powerful checks and balances instigated by the currentinvention. It is obviously intended to encourage physicians to beadherent to EBM guidelines (or other performance standards) or providetheir patients a legitimate reason for non-adherence. It is alsointending for patients to be knowledgeable and discriminating about thehealthcare they receive. In effect, the health plan is compensating boththe physician and patient to participate in this check and balance withthe expectation that better healthcare will rendered, and that this willlead to better health and lower costs. It is important to note that oneof the most important aspects of the method (invention), which makes itespecially attractive to physicians, is its “anti-cookbook medicine”feature. This feature allows physicians to answer this guidelineadherence question either “yes” or “no,” and still earn fullcompensation for practicing the method. The reason the health plansponsor would agree to pay physicians when they answer this question“no” is because the method requires physicians to select a reason fornon-adherence to a guideline from a pop-up menu refer to FIGS. 9A and9B). The physician's reason for non-adherence is stored in the Website'sdatabase to be presented to the patient later in the process. The healthplan sponsor knows that the physician is aware that his/her reason fornon-adherence will be judged by an informed patient. This check andbalance solves the issue physicians have had with “cookbook medicine”associated with other pay-for-performance methods that force them tofollow a protocol or guideline to be compensated. In fact, this featureencourages physicians to answer “no” when it is appropriate, as tong asthe patient is educated as to why a guideline does not fit his/herparticular health condition,

b. “Which patient education articles do you wish to prescribe to thispatient?” The Website attempts to make prescribing educational materialfast and easy for the service provider to complete (See FIG. 9c ). Asshown in FIG. 9c , multiple articles are listed relevancy order to thediagnosis. The service provider simply selects one or more of thearticles as information therapy for the patient. The Website alsoprovides a means for the service provider to preview the articles, seewhich articles he/she prefers for this diagnosis, and see which articleshe/she and other service providers have prescribed to the patient in thepast. The Program also presents the service provider with a listing ofhis or her favorite articles or previously prescribed articles. Thepresentation of information shown in FIG. 9c is based on storedinformation keyed to the diagnosis code received, the service providerand the patient's history. It should also be noted that this act ofprescribing information therapy is extra effort exerted by thephysician, which supports the case for additional pay. It should befurther noted that many health plan sponsors are not enthusiastic aboutpay-for-performance programs that compensate physicians more for merelyfollowing a recommended treatment guideline because health plan sponsorsfeet this is what the physician is being paid to do in the first place.This is not the case in the Ix Program's method.

-   -   c. “Please rate your patients compliance for this diagnosis:        Compliant; Compliance is a non-factor; or No response” or        “Compliant. Mostly Compliant; Somewhat Compliant; Mostly        Non-compliant; Non-compliant”        This is an optional question that a health plan sponsor can        elect to have added to the Ix Program before or after the        patient participates in the Ix Program. The health plan sponsor        may assign a portion of the patients financial reward based on        how the physician answers this question. The service provider's        response to this question is not made available to the patient        to prevent undermining doctor-patient relations,

Once the physician answers these questions, the POSI real-time versionof the Ix Program model allows the physician to print an informationtherapy prescription to hand to the patient before the patient leavesthe office. Alternatively, the physician can practice the real-timeversion at the end of the day for all enrolled beneficiaries, and theintermediary will mail or e-mail the prescriptions to each patient, (Inthe CI after-the-fact version, all Ix prescription letters are sent bymail or e-mail or text message.) The process continues for the physicianwhen he or she is asked to review and consider patient responses to theWebsite's questionnaires. These responses are available to the physicianthrough the Website. Responses that indicate the patient is experiencingadditional medical issues or distress is sent to the physician as apriority e-mail notice. Since physician participation in the Ix Programis voluntary on a per-occurrence-of-care basis, the act of participationby a physician is an indication that the physician is committed todelivering a higher standard of care, is committed to better patientcommunication, is interested in patient compliance to recommendedtreatments, and is willing to have his/her performance judged by his/herpatient, Conversely, a physician's non-participation may imply a wholeother set of values that may result in patient and health plan sponsordissatisfaction,

The Physicians' level of participation and patient ratings are intendedto aggregated over time. Typically, these results will be used first torecognize the service providers with the highest rate of participationand the highest patient ratings. These results can also be madeavailable to physician peer review organizations to provide a degree ofdue process for the poor performing service providers. Eventually theseresults are to be made available to health plan sponsor and the generalpublic, thus allowing market forces to provide additional motivation(incentive). But perhaps the most powerful incentive to the physician ishis/her desire to prevent his/her patients from thinking he/shepractices inferior medicine,

In other models of the invention, different types of performancestandards can and will be accommodated. However, the process of theservice provider (physician/clinician/medical practitioner) being askedto demonstrate or declare adherence or reason for non-adherence to agiven performance standard with the understanding that his/her patientwill confrim/rate/concur with the service's providers indication ofadherence, followed by the patient being asked to learn anddemonstration knowledge about the performance standard and, oncequalified, being asked to rate the service provider's indication ofadherence to the performance standard remains the same for all types ofperformance standards. The optional process step of physicians ratingtheir patients' adherence to recommended care and the process step ofphysicians having access to their patients' Website responses (includingmedical issue warnings) also remain the same for all types ofperformance standards. The invention is most effectively deliveredthrough the Internet, though it can be delivered by telephone ortelephonic interface or other means, provided that the parties and theother elements of the invention remain the same as described herein.

At Steps #8 a and 8 b of the current invention, the patient receives andresponds to the Ix prescription letter/email/text message/notificationfrom the intermediary. In the Ix Program model of the invention, thepatient can receive his/her information therapy (Ix) prescription letterfrom his/her physician as he/she leaves the physician's office or bymail or e-mail. If the physician fails to participate or fails tosuccessfully complete an “Ix opportunity,” then the diagnosis listed onthe medical service claim for payment submitted by the physicianprovides the means by which the intermediary's computer system canautomatically generate the notification to the patient that informs thepatient of his/her chance to participate in the Ix Program for said “Ixopportunity.”

The prescription letter directs the patient to access the Website (Step#8 b) (See also FIG. 10) where his/her actual prescription will be readyand waiting as a result of the physician's earlier responses to theWebsite or, when the physician fails to participate in the “Ixopportunity”, as a result of the medical service claim for paymentsubmitted by the physician. For each diagnosis entered by the physicianassociated with this occurrence of care, the beneficiary/patient isasked to do the following on the Website to earn his/her financialreward:

-   -   1. Read the health information about his/her diagnosis,        including EBM treatments, recommended care, health maintenance,        and/or other performance standards (refer to FIG. 11);    -   2. Answer a questionnaire to indicate or assess his/her        knowledge or understanding of the health information (refer to        FIG. 12A). If an incorrect answer is received the patient may be        presented with the exemplary webpage shown in FIG. 12B which        provides the patient with notice that is has answered        incorrectly and directs them to the correct answer;    -   3. Answer a questionnaire about his/her current health status;    -   4. Answer a questionnaire about his/her compliance to the        recommended care (See FIG. 13);    -   5. Answer a questionnaire about releasing his/her responses to        the questionnaires about his/her knowledge or understanding of        the health information, his/her health status, and his/her        indication of compliance to the recommended care to his/her        physician (See FIG. 14);    -   6. Answer a questionnaire to rate his/her physician's        performance against EBM treatments, recommended care or other        performance standards as:        -   Consistent;        -   Mostly Consistent;        -   Somewhat Consistent;        -   Mostly Inconsistent;        -   Inconsistent        -   or review any reasons recorded by the physician for            non-adherence to the treatment guideline or other            performance standards and answer a questionnaire to express            a qualified opinion in regards to the physician's reason for            non-adherence (See FIG. 15); and    -   7. Alternatively, elect to authorize the release of the        physicians rating of his/her compliance to recommended care (if        the physician is asked this question),

Depending upon how or if the patient answers these questions, he/shescores points toward a financial reward for this occurrence of care (Ixopportunity). Once his/her point total reaches a required threshold, theWebsite presents a voucher (See FIG. 16) that notifies the patient thathe/she has earned the financial reward offered by his/herpurchaser/payer. (Note that the physician rating questionnaires can bemade even more objective by asking the patient to qualify his/her ratingresponse. For instance, if the patient's diagnosis is hypertension andthe patient rated the physicians performance as “Consistent,” then theProgram can drill down by asking the patient if the physician informedhim/her about controlling salt intake or being sure to stay on his/hermedication or that he/she should check his/her blood pressure regularly.Again, this provides a more objective means of rating physicians thanthe prevalent use of subjective satisfaction surveys)

The patient's participation and authorization to release his/herresponses to the questionnaires to his/her physician is an indicationthat the patient wants his/her physician to know he/she understands howto self-manage his/her medical condition and is committed to beingcompliant to recommended care and healthy behaviors or is providing areason he/she is willing to share with his/her physician as to whyhe/she is not being compliant. In the process, the patient learnsvaluable information that he/she may have not known or did notunderstand or forgot to ask the physician that can be used to betterself-manage his/her health. In addition, the patient gains the peace ofmind that he/she is receiving EBM treatments or other standard ofperformance from his/her physician. Finally, the patient receives afinancial reward for his/her effort and healthy behavior.

As with service providers (physicians/doctors/clinicians/medicalpractitioners/healthcare providers), other types of performancestandards can and will be accommodated by the current invention.However, the process of the patient (beneficiary/health plan member)being asked to demonstrate or declare his/her health literacy andadherence (or provide a reason for non-adherence) to a given performancestandard, agreeing to allow the physician toreview/confirm/rate/acknowledge his/her health literacy and indicationof adherence to the performance standard(s), and theconfirming/rating/concurring with/acknowledging the physiciansdeclaration or demonstration of the adherence or reason fornon-adherence to performance standards remains the same for all types ofperformance standards. The optional process step of physicians ratingtheir patients adherence to recommended care and the process step ofphysicians having access to their patients' Website responses (includingmedical issue warnings) also remain the same for all types ofperformance standards,

Referring still to FIG. 3, in Step #8 c the patient agrees to allow theservice provider to review/confirm the patient's responses to thequeries posed the patient in Steps 8 a, and 8 b.

In Step #9, the physician and patient confirm each other's performanceusing the Internet application. As mentioned in reference to Steps #7and #8, the method asks the physician and patient to review and confirmeach other's declarations or demonstration of adherence or reason fornon-adherence to an EBM benchmark and/or other performance standards.Both parties are aware they must agree or acknowledge that the otherparty can and may confirm/rate/acknowledge/concur with their declarationor demonstration of adherence or reason for non-adherence to the EBMbenchmark and/or other performance standards in order to earn thefinancial rewards offer through the Ix Program. Physicians do not wanttheir patients to think or learn they practice inferior medicine.Conversely, patients (especially patients with chronic conditions thathave close relationships with their physicians) do not want theirphysicians to think they are health illiterate or non-compliant withrecommended treatments and health behaviors. As a result, physicians andpatients are motivated to please one another by gaining health literacy,adopting healthy behaviors, following recommended treatments anddelivering high quality healthcare. Furthermore, since both parties areaware that their responses are being recorded and stored by anindependent third party (the intermediary), and that this informationcould be reported to the health plan and, in the case of physicians, thegeneral public, then both parties are even more motivated to gain healthliteracy, adopt healthy behaviors, follow recommended treatments anddeliver high quality healthcare. In effect, the method's processes thatcombine the attributes of financial (behavioral economics andnon-financial (health psychology) motivators (i)centives) createspowerful “checks and balances” (“mutual accountability”) that encouragesa higher standard of care and healthier behavior that leads to lowercosts.

At Step #10, the physician files a health insurance claim with thehealth plan. As mentioned with reference to Steps #4 and #5, the normalfiling of an insurance claim by the physician for medical servicescovered by the Ix Program can occur before, concurrently, or after themethod is practiced by the physician. (An insurance claim contains allthe information needed by the Ix Program's web-based softwareapplications to complete the process.) The claim must be filed within acertain time limit established by the health plan sponsor and theintermediary. If a physician does not access the Website and practicedthe POSI real-time version of the method by the time the physician'sclaim reaches the intermediary, then the CI after-the-fact version ofthe method will send an e-mail notification to the physician. This isreferred to as a “CI opportunity.” The physician will have a time limitto respond to a “CI opportunities.” If a “CI opportunity” expires, thehealth plan sponsor and the intermediary may elect to send the patientan Ix prescription based on the diagnosis(es) listed on the insuranceclaim submitted by the physician. This allows patients to gain valuablehealth information and earn a financial reward, even when theirphysicians fail to participate in the Program. This process is referredto as “system-generated information therapy.” To encourage physicianparticipation while insuring patients are not deny the opportunity toparticipate in the Ix Program when their physician fail/forget toparticipate, the health plan sponsor and the intermediary can offerpatients larger financial rewards for “physician generated Ix” than for“system-generated Ix.”

Step #11 comprises the health plan/payer sending claim information tothe intermediary. A plan administrator can be a third partyadministrator (TPA) or a health insurer's administrative services only(ASO) contracted be a self-insured employer (t)e health plan sponsor) orthe health insurer (the health plan sponsor) in the case offully-insured employers and individuals or government agencies. The planadministrator forwards all insurance claims to the intermediary.Preferably, claims are sent automatically and electronically on a dailybasis, using industry standard electronic data interchange (EDI)interfaces and formats. Once downloaded into the intermediary'scomputer, the Ix Program's software applications sort the data to findclaims containing covered medical services (applicable medical services)rendered to beneficiaries covered by the Ix Program.

Step #12 comprises the intermediary matching claims to “opportunities,”then authenticates and adjudicates physician and patient Websiteresponses, and directs financial compensation and other rewardnotifications to the health plan/payer. As described with reference Step#5, above, the intermediary uses the Website's software applications tomatch insurance claims to physician POSI responses stored in theintermediary's database. If there is a match, the intermediary sends an(electronic) authorization/directive to the plan administrator tocompensate the physician (and sends the information therapy prescriptionto the patient as described in Step #7, above). Since the POSI real-timeversion is the preferred method, the intermediary can select a premiumor highest rate of compensation for the physician. If the intermediarycannot match an applicable insurance claim to a POSI, then the ClaimInitiated or CI version of the method sends an email notification to thephysician. If the physician responds to the “CI Opportunity” andsuccessfully practices the method within the allotted time, then theintermediary sends an (electronic) authorization/directive to the planadministrator to compensate the physician (and sends the informationtherapy prescription to the patient as described in Step #7, above).Since the POSI real-time version is the preferred method, theintermediary can select a tower rate of compensation for the physicianpracticing the CI after-the-fact version of the method. The Websiteapplications track patient information therapy and other performancestandards responses. When a patient successfully completes an Ixprescription or other performance standard through the Website (or overthe telephone or by other means), then the Ix Program's softwareapplications adjudicate the patient's reward and the intermediary sendsan authorization/directive to the plan administrator to pay the assignedreward to the patient. If the physician or the patient do notindependently and individually (or perhaps dependently and collectively)respond to their respective “Ix opportunities” within establishedtimeframes, then the Ix Program software applications close-out eachopportunity accordingly, and the physician and patient do not earnfinancial compensation or rewards. All of these events are recorded andstored for future consideration by the intermediary and the health plan.

Step #13 comprises the health plan sponsor, through the planadministrator, compensating the physician. When the plan administratorreceives the payment authorization/directive from the intermediary, theplan administrator reimburses the physician one of multiple levels ofcompensation according to the contracted terms between the health planor intermediary and the physician. Alternatively, the health plansponsor may assign the physician and payment function to theintermediary. In this case, the intermediary makes payments tophysicians from funds supplied by the health plan sponsor. In thecurrent invention and under the terms of the agreement between thehealth plan or intermediary and the service provider, varying amounts ofcompensation can be paid for a variety of performances standards.

At Step #14 the health plan sponsor, through the plan administrator,pays the beneficiary a financial reward. When the plan administratorreceives the payment authorization/directive from the intermediary, theplan administrator pays the patient one of multiple levels ofcompensation according to the benefit established by the health plansponsor in consultation with the intermediary and the performancestandard achieved by the patient. Alternatively, the health plan sponsormay assign the payment function to the intermediary. In this case, theintermediary makes payments to patient from funds supplied by the healthplan sponsor,

Step #15 comprises the health plan sponsor realizing a cost savings.Though this is not an actual step in the process, the intendedby-products of the method is a higher standard of care (featuring EBMtreatments and information therapy) and healthier behaviors that studieshave shown leads to lower costs. In the current invention, the healthplan sponsor agrees to compensate medical providers and patients to“declare and confirm” their adherence to performance standards, and tocompensate the into mediary for operating the system and authenticatingphysicians and patients' declarations and confirmations. Morespecifically, the health plan sponsor agrees, in order to achieve costcontainment as a result of better health and healthcare, to:

1. compensate the medical provider (physician and hospital) foraccessing the Website to:

-   -   a. declare or demonstrate adherence or providing a reason for        non-adherence to evidence-based treatments and other provider        performance standards;    -   b. agree or acknowledge the provider's patients will        confirm/rate/concur with/acknowledge his/her declaring or        demonstrating adherence or providing a reason for non-adherence        to evidence-based treatments and other performance standards        after patients demonstrate they understand the treatments on the        Website;    -   c. prescribe information therapy and other performance standards        to the patient;    -   d. optionally, rate his/her patients' level of adherence to        recommended care; and    -   e. responding to his/her patients' responses to the Website's        questionnaires and inputs to include warnings of medical issues

2. financially reward patients (benficiaries) for accessing the Websiteto:

-   -   a. read prescribed educational material as information therapy;    -   b. declare or demonstrate (by tests) his/her understanding of        the educational material (health literacy), especially as it        pertains to self-managing his/her health and the recommended        treatments;    -   c. declare or demonstrate adherence or providing a reason for        non-adherence to the recommended treatments, healthy behaviors        and other related performance standards;    -   d. report his/her health status;    -   e. agree to allow his/her medical providers to        review/rate/acknowledge his/her health literacy, health status,        and indication of adherence responses;    -   f. confirm/rate/concur with/acknowledge his/her medical        providers' declaration or demonstration of adherence or reason        for non-adherence to evidence-based treatments and other        performance standards;

3. compensate the intermediary for:

-   -   a. operating the invention's incentive system to include the        Program's Website and/or other technologies;    -   b. developing and maintaining the associated software        applications and databases;    -   c. providing and/or interfacing the performance standards        supplied by vendors;    -   d. the performance standards;    -   e. adjudicating and authenticating medical providers and        patients' declarations, confirmations, demonstrations, and        acknowledgments of adherence to performance standards;    -   f. adjudicating and authenticating medical providers and        patients' agreements and acknowledgments to allow the other        party's declarations, confirmations, demonstrations, and        acknowledgments of adherence to performance standards;    -   g. directing and/or affecting service provider and patient        compensation and financial rewards;    -   h. tracking, reporting, and analyzing results; and    -   i. recommending refinements to the Program to include “precision        guided incentives and performance standards (adjustments to and        expansion of the incentives and performance standards).

By combining the parties and elements of the method in the mannerdescribed herein, the invention “triangulates” the interests ofhealthcare's key stakeholders the health plan, the medical provider andthe consumer/patient—in a win-win-win arrangement. By attaining thisunique “triangulation” among these key stakeholders, the inventionachieves the goals of better health and better and more affordablehealthcare. Thus the invention can be described as a “web-basedhealthcare incentive system” that creates an “alignment of interests”and a “state of equilibrium” and a “mutual accountability' partnership”among the key stakeholders to achieve the goats of better health andbetter and more affordable health care. As a result, the invention isbetter described as an “alignment of interest” or “AOL” program asopposed to the more familiar pay-for-performance program descriptor.

Other embodiments of the current invention wilt be apparent to thoseskilled in the art from a consideration of this specification orpractice of the invention disclosed herein. However, the foregoingspecification is considered merely exemplary of the current inventionwith the true scope and spirit of the invention being indicated by thefollowing claims.

What is claimed is:
 1. A method for managing a patient's health and healthcare costs, the method comprising: authenticating an electronic device to a computer that stores a patient account record corresponding to a patient identification; commanding the computer to generate and transmit a unique patient webpage for display on the electronic device using data from the patient account record; wherein the patient webpage comprises an opportunity to earn a financial reward associated with a medical service that is unique to the patient account record, the opportunity comprising a healthcare provider name and a patient diagnosis associated with a date of service, an expiration date assigned to the opportunity by the computer, and a patient session link to instruct the computer to generate and display an information therapy prescription, a patient knowledge exam, a patient declaration link, a patient agreement link, and a patient rating link; displaying the information therapy prescription at the electronic device; displaying the patient knowledge exam on the electronic device, the knowledge exam comprising a plurality of questions related to the information therapy prescription and selected by the computer from a question database; receiving input signals from the electronic device, the signals comprising answers to the plurality of questions; creating and displaying a new webpage when an incorrect answer is received directing the patient to a question with the incorrect answer and a portion of the information therapy prescription containing a correct answer; activating the patient declaration link to transmit a signal from the electronic device to indicate a patient declaration of adherence or reason for non-adherence to the information therapy prescription; receiving the signal from the patient declaration link, the signal comprising an answer to the patient declaration of adherence or reason for non-adherence to the information therapy prescription; amending the patient account record to indicate a patient declaration of adherence or reason for non-adherence to the information therapy prescription; activating the patient agreement link to transmit a signal used to amend the patient account record to indicate a patient agreement to release the patient's answers to the plurality of questions and the declaration of adherence or reason for non-adherence to the information therapy prescription and to the healthcare provider; activating the patient rating link to transmit a signal indicative of the patient's answers to the rating of the healthcare provider; and thereafter, the computer authorizes disbursement of the financial reward to the patient.
 2. The method of claim 1 wherein the electronic device comprises an Internet or application enabled device.
 3. The method of claim 1 wherein authenticating the electronic device to the computer comprises receiving the patient identification and an authentication factor both corresponding to the patient account record at the computer.
 4. The method of claim 1 wherein the electronic device and the computer communicate via the Internet.
 5. The method of claim 1 wherein the patient web page comprises a plurality of opportunities to earn financial rewards each comprising an entry on the patient account record comprising the healthcare provider name and the patient diagnosis associated with a date of service, the expiration date of the opportunity assigned by the computer, and the patient session link.
 6. The method of claim 1 further comprising before displaying the information therapy prescription and the knowledge exam on the electronic device, the computer automatically processes the patient account record to determine if the expiration date assigned by the computer has passed, thereafter the computer does not authorize disbursement of the financial reward to the patient if the computer determines the expiration date has passed.
 7. The method of claim 1 further comprising creating and sending an electronic mail message or postal notice to the patient of the opportunity to earn a financial reward associated with a medical service before displaying the unique patient webpage.
 8. The method of claim 7 wherein the electronic mail message comprises an active link to the unique patient webpage.
 9. The method of claim 1 further comprising the computer establishing a threshold dwell time for the electronic device to display the information therapy prescription and measuring the dwell time, authorizing disbursement of the financial reward if the measured dwell time meets or exceeds the threshold dwell time.
 10. The method of claim 1 wherein the information therapy prescription comprises an educational material selected by the computer based on the patient diagnosis.
 11. The method of claim 1 wherein the patient's rating of the healthcare provider is aggregated with ratings from a plurality of patients and transmitted by the computer to the healthcare provider as a composite performance rating.
 12. The method of claim 11 wherein the computer uses the composite performance rating to determine a level of compensation to the healthcare provider.
 13. The method of claim 1 further comprising instructing a health plan to disburse the financial reward to the patient.
 14. The method of claim 12 further comprising instructing a health plan to disburse the financial reward to the healthcare provider.
 15. A computer implemented method for managing health and healthcare costs, comprising executing on a processor the steps of: creating a financial reward opportunity record for a patient based on a patient identifier and a medical diagnosis code associated with a medical service rendered by a healthcare provider to the patient received in a first electronic message; assigning a time limit to the financial reward opportunity record; linking an information therapy selected from an information therapy database to the financial reward opportunity record; linking a randomly selected query related to the information therapy from a plurality of queries stored in a query database to the financial reward opportunity record; receiving a second electronic message comprising the patient identifier and requesting access to the financial reward opportunity; in response to the second electronic message, accessing the financial reward opportunity record to create and transmit a patient session webpage comprising the medical diagnosis code, the selected information therapy, the query, and an active link to generate a third electronic message comprising a patient declaration of adherence or reason for non-adherence to the information therapy, a patient answer to the query, and a patient agreement to release the patient answer and the patient declaration of adherence or reason for non-adherence transmitted to the healthcare provider; receiving and processing the third electronic message to write the patient declaration of adherence or reason for non-adherence, the patient answer, and the patient agreement to release to a patient record and to confirm receipt of the third electronic message prior to the time limit; and thereafter authorizing disbursement of the financial reward to the patient.
 16. The method of claim 15 further comprising processing the patient answer to the query and creating and displaying a new webpage when the patient answer is incorrect, the new webpage comprising the query for which the patient answer was given and at least a portion of the information therapy containing a correct answer to the query.
 17. The method of claim 15 further comprising: receiving a healthcare provider identification at the computer from a provider electronic device; processing the healthcare provider identification to create and transmit a healthcare provider webpage for display on the provider electronic device, the healthcare provider webpage comprising a plurality of fields to receive data from a healthcare provider containing the patient identifier and the medical diagnosis code; wherein the computer receives the patient identification and the medical diagnosis code and generates a healthcare provider prescription page for display on the provider electronic device, the prescription page comprising plurality of active links for the healthcare provider to select an offer of a healthcare provider financial compensation, a healthcare provider performance standard, a patient performance standard and information therapy corresponding with the medical diagnosis code, and an expiration date assigned to the offer by the computer; the computer processes the data received from the prescription page and generates a unique declaration page corresponding to the patient identification and the medical diagnosis code comprising a plurality of active links to receive and transmit data from the provider electronic device to the computer comprising a healthcare provider declaration of adherence or reason for non-adherence to the healthcare provider performance standard, a healthcare provider acknowledgment that the patient will rate or confirm the healthcare provider declaration of adherence or reason for non-adherence, a patient performance standard and information therapy prescription, and an agreement to confirm and acknowledge the patient declaration of adherence or reason for non-adherence; the computer receives the data from the declaration page and automatically processes the data to determine if the healthcare provider has declared adherence to the healthcare provider performance standard or provided a reason for non-adherence that corresponds to at least one reason for non-adherence from plurality of preselected reasons for non-adherence stored in a database at the computer; and the computer issues a command signal to order disbursement of the healthcare provider financial incentive to the healthcare provider based upon authentication of the data received from the prescription page and the healthcare provider declaration of adherence or authorized reason for non-adherence, if the expiration date has not passed.
 18. The method of claim 17 further comprising processing data received from the prescription page to generate the patient session webpage.
 19. The methods of claim 17 wherein the command signal is transmitted to a health plan computer, and comprises an order to disburse the service provider financial incentive comprising monetary compensation to the service provider.
 20. The method of claim 15 further comprising before transmitting the patient session webpage, the computer automatically processes the financial opportunity reward record to determine if the time limit has passed, thereafter the computer does not authorize disbursement of the financial reward to the patient if the computer determines the time limit has passed. 